Oral Health and the Triple Aim: Evidence and Strategies to Improve Care and Reduce Costs
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APRIL 2015 Oral Health and the t a t e e a l t H o l i c y riefing P r o v i d e S a n o v e r v i e w a n d a n a ly S i S So f e m eH r g i n g i ssPu e S a nB d d e v e l o P m e n t S in S t a t e H e a l t H P o l i c y . Mounting evidence suggests that Triple Aim: Evidence addressing oral health can help states move toward the Triple Aim goals and Strategies to Improve of improved patient care, improved population health, and reduced per- Care and Reduce Costs capita costs. Oral health and overall health intersect in three important areas for states’ reform efforts: diabetes, maternal and child health, and avoidable emergency department use. State strategies to leverage these linkages include covering adult dental services in Medicaid; building connections between oral health care Andrew Snyder and medical care in service delivery, professional education, and licensing; and incorporating oral health into health reform efforts. Poor oral health—including high rates of tooth decay, missing teeth, and gum disease—and inadequate access to oral health services are persistent problems for low-income populations. More than 40 percent of adults below the Federal Poverty Level have at least one untreated decayed tooth,1 but fewer than 20 percent of poor adults aged 19-64 receive any dental services.2 This low level of access is costly. Many low-income individuals turn to the emergency department as their primary and only source of care for oral health needs, and these visits for avoidable oral-health-related visits cost the U.S. health care system hundreds of millions of dollars per year. 3, 4 Oral Health And The Triple Aim: Evidence And Strategies To Improve Care And Reduce Costs Or a l He a l t H ’s li n k s t O Ov e r a l l He a l t H a n d He a l t H CO s t s Although state and federal policymakers are pursuing many strategies to reform health care delivery and move toward the Institute for Healthcare Improvement’s Triple Aim of improving the patient experience of care, A 2011 Institute of Medicine (IOM) report concluded that “oral health is an integral part of overall health, and improving the health of populations, and reducing the 7 5 per-capita cost of care, oral health is very often left therefore, oral health care is an essential component of out of the equation. Accountable Care Organizations, comprehensive health care.” Although oral health care patient-centered medical homes, and the federal State delivery, financing, and provider training systems have Innovation Models grant program have focused on historically been separate from medical care systems, coordinating care for patients with complex needs, the mouth is not separate from the rest of the body. delivering whole-person care that integrates primary Conditions affecting the mouth and teeth have effects and specialty care, including behavioral health, and on organs and systems throughout the body, and vice addressing the drivers of health spending. Few of these versa. initiatives, however, currently include oral health, despite Pain from cavities and abscessed teeth can be severe, a growing body of research indicating an important and can make it difficult to engage in daily activities like 8 connection between oral and physical health. eating, speaking, or smiling. Poor oral health is related 9 The effects of poor oral health are not limited to the to frequent school absences. Oral cancers are very mouth. In addition to pain, lost work time, poorer common and many cancer treatments affect oral health. Many common drugs can cause dry mouth, which can nutrition, and avoidable costs from failing to prevent oral 10 disease, a variety of studies have associated oral disease increase the risk of oral health problems. The earliest with systemic health conditions including cardiovascular manifestations of HIV often occur in the mouth. disease and diabetes. Several studies of private insurance Oral health and overall health also intersect in three claims indicate that people with diabetes receiving particular areas important to states’ reform efforts: treatment for gum disease had total costs that were 6 diabetes, maternal and child health, and avoidable thousands of dollars lower than those who did not emergency department use. The sections below describe receive such treatment. research in each of these areas and provide examples State policymakers have an opportunity to build of how adopting an oral health strategy could provide on several notable national and state initiatives and states with another way to improve patient experience, local pilot projects that address educational and improve population health, and reduce health costs. programmatic barriers to bridging oral health and i a b e t e s a n D g u m D i s e a s e medical care. States seeking to pursue this opportunity D can focus on coverage of adult dental benefits in Diabetes is an important driver of health spending in Medicaid; building connections between oral health the United States. The Centers for Disease Control and care and medical care in service delivery, professional Prevention (CDC) estimates that in 2012, 29.1 million Americans had diagnosed or undiagnosed diabetes, and education, and licensing; and inclusion of oral health 11 goals in broader delivery reform efforts. direct health spending related to diabetes totaled $176 billion. Medicaid covered 15 percent of individuals This brief will describe research on oral-systemic with diagnosed diabetes in 2003. Medicaid enrollees 12 linkages, state-level experiences with incorporating with diabetes had annual per capita health expenditures oral health into reform strategies, and promising local of more than $13,000, compared to per capita 13 examples. It will also describe next steps for states expenditures of $5,844 across all Medicaid enrollees for wishing to incorporate an oral health strategy into the most recent available year. their reform efforts. NASHP will also be publishing a companion online toolkit for state policymakers that will There is a two-way relationship between gum (periodontal) disease and glycemic (sugar) control in provide more informationNational on areas Academy described for State here. Health Policy people with diabetes. Individuals with diabetes are at : 2 : Download this publication at: www.nashp.org Oral Health And The Triple Aim: Evidence And Strategies To Improve Care And Reduce Costs much higher risk of developing gum disease, and chronic 14 inflammation and infection from periodontal disease can x a m p l e in r o g r e s s make it more difficult to control blood sugar levels. a m i l y e a l t H e n t e r pa r s hf i e l D Uncontrolled blood sugar can cause serious and costly F i s C o nH s i n C , m , complications, including blindness, amputation, heart W disease and kidney disease. Family Health Center of Marshfield, Inc., a large federally qualified health center system in Several studies of claims data from commercially-insured Wisconsin, and the Marshfield Clinic, one of the populations have estimated significant cost savings from 15 largest private group medical practices in the providing frequent dental cleanings and periodontal state, are working together on initiatives to better therapy to members with diabetes. integrate medical and dental care for people with • A study of data from United Concordia (a dental diabetes by taking advantage of Family Health insurance company) and Highmark, Inc. (a medical Center’s network of large dental clinics across the insurer), published in the American Journal of northern and western parts of the state. Marshfield Preventive Medicine, found that individuals with Clinic is developing a fully integrated medical type 2 diabetes who received regular periodontal and dental electronic health record, and clinical treatment had medical costs that averaged $2,840 decision support tools to assist both dentists 16 less per year, from avoided hospitalizations and and physicians in co-management of patients reduced utilization of medical services. with diabetes. Family Health Center dentists at pilot sites now monitor diabetics’ blood sugar • A 2006-2008 CIGNA study estimated annual in the dental office, and medical providers are medical cost savings of $2,483 per person—a 23 able to track whether their diabetic patients are percent reduction—for individuals with diabetes receiving treatment for gum disease, as well as who completed periodontal therapy, compared to 17 conduct routine visual oral examinations along those who started but didn’t complete treatment with annual foot and eye exams. Grant funding for gum disease. from the DentaQuest Foundation supported a • A 2009 study of Blue Cross Blue Shield of Michigan pilot program, conducted in coordination with a claims found savings of 10 percent annually in managed care plan, to test patient education and 24 diabetes-related medical care costs from treating incentive strategies to encourage individuals with gum disease, and savings of between 20-40 percent 18 diabetes to establish regular oral health care. for individuals with diabetes and another chronic While evaluation of their integrated care projects is condition. still ongoing, Family Health Center and Marshfield In response to studies such as these, insurers are Clinic intend to expand the pilots to additional beginning to change their policies. For example, United medical and dental service delivery sites in the Concordia established Smile for Health—Wellness, coming year. an integrated program of improved dental benefits State policies underpin these efforts.