Let’s improve oral health with provider-focused, patient-centric Medicaid dental partnerships

States and managed care organizations face real challenges when it comes to running a successful Medicaid program and helping people get and stay healthy. Medicaid leaders find themselves faced with extremely difficult decisions about how best to prioritize critical needs of the population – often times there are no silver bullets. Yet, Medicaid dental partnerships are a great step forward.

In the past, the dental component of a Medicaid program has fallen victim to tough decisions, receiving fewer resources and lagging behind when it came to ensuring access to needed care. And people suffered.  

Recognizing this, states started to look at their Medicaid dental programs differently. They began seeking out industry experts like DentaQuest to help work directly with Medicaid agencies or to support managed care organizations to implement best practices. 

The result was that more people got access to the medically necessary oral health they needed.

   

Rapidly expanding regulatory requirements and Medicaid budget pressures, as well as the tidal wave of value-based payment and care models initiated by the Affordable Care Act, mean states once again find themselves at a crossroads when it comes to their Medicaid dental programs.  

Forward thinking states are moving past the notion that access to treatment is all it takes to improve the oral health of all. They recognize that an effective Medicaid dental program must achieve the Triple Aim: lower costs, improved population health, and better patient experiences.  

Tennessee is a perfect example of a dental partnership focused on the triple aim. 

In 2012, state Medicaid leaders recognized they were no longer meeting the oral needs of the people they served and set out to create a new Medicaid dental program model. They also recognized that they needed a new partner, not just a vendor, to help develop and implement a holistic approach to oral health.   

Today, DentaQuest partners with the state to administer the TennCare Medicaid dental program and through this partnership, more children have access to preventive care at a lower cost to taxpayers.  

Since partnering with TennCare in 2013, DentaQuest has saved the state $27.5 million by prioritizing preventive care, which helps to avoid extensive, costly future procedures. In the second year of the program, the number of children participating in the program increased by 8 percent to 810,000 enrollees. Through our dental home program, we’ve made sure that each and every one of the 810,000 children is connected to a dentist who is willing and able to provide care.  

TennCare has been able to handle the influx of patients thanks to a provider participation increase of 31 percent. DentaQuest has focused on easing the administrative burdens placed on providers and facilitating transparent communications.  

This successful model is built upon the idea that aligned incentives can improve outcomes.  

DentaQuest has a shared responsibility when it comes to improving outcomes and reducing costs. This challenge should not fall on providers and states alone. DentaQuest must meet outcome benchmarks—set by the state—related to access, network adequacy, outreach, and cost.  

DentaQuest met or exceeded benchmarks in all categories during the first two years and is poised to demonstrate success again in year three.   

The results of this model are encouraging: 

• Average distance to a provider is 3.7 miles, compared to a benchmark of 30 miles 
• Wait times for routine, urgent, and emergency care are significantly lower than the state’s thresholds 
• 100 percent of beneficiaries have patient-centered dental homes—providing accessible, comprehensive, and coordinated care to enrollees 

 

DentaQuest has been able to succeed in part by educating and engaging patients and families—even hosting over 80 community events last year.  

This type of patient-centric program should serve as a model for other state Medicaid programs and partners. Change and innovation should not mean complexity and burden. 

There is a better way forward and DentaQuest has a roadmap to get there.  

Dental Health Care Needs Quality Improvement Now

The message couldn’t be clearer: The time for the dental profession to jump on the health care quality improvement (QI) bandwagon is now.

In the past quarter-century, the United States has seen medical care improve and per capita health care costs go down thanks to QI standards adapted from other industries like manufacturing. But why has the dental profession been so slow to join the game? Our recent DentaQuest Institute editorial in the July/August 2016 issue of Pediatric Dentistry provides some clues.

In our editorial, we argue that, because of QI’s effectiveness—in medicine and other fields—it is 

“...imperative that dental professionals create the culture and systems necessary to apply QI principles and activities for the benefit for our patients, the public at large, and our profession.” 

That may be easier said than done, but our own Dr. Natalia Chalmers, who heads DentaQuest Institute’s Analytics and Publication team, and her colleagues lay out a number of programs that place a heavy emphasis on QI - from DentaQuest Institute’s EarlyChildhood Caries (ECC) program and the UCLA-First 5 LA Oral Health Program to new initiatives from the American Dental Association’s Dental Quality Alliance. 

The common thread with these programs: they all work.

• Through ECC Collaborative, an effort to reduce dental caries in young children, 32 federally-qualified health centers (FQHCs) significantly improved patient outcomes after implementing a disease-management approach to QI.
• The UCLA program helped 22 local FQHCs redesign workflows based on QI models, improving diagnostic, preventive and treatment services in participating dental clinics. With the “triple aim” of improving patient experiences, improving health status, and lowering costs, the ADA’s Dental Quality Alliance seeks to help dental practices establish processes “to reliably deliver evidence-based care to every patient.”

The authors note small steps may be all that’s needed to push the profession toward QI. For example, the Plan-Do-Study-Act cycle results in a trial-and-error approach until performance improvements are realized. This practice has helped improve quality performance in industries from high-tech to higher education. There’s no reason dentistry can’t do the same.

They also understand that integrating QI into a dental practice requires considerable planning, coordination and commitment. And it takes a team for QI to take root. Dental practitioners, office staff and even patients must be invested in the process for it to work.

That said, dentists need to begin thinking now about QI at the practice level. These efforts will have an enormous impact on the way dental care is delivered. And, as the DentaQuest editorial illustrates, that’s a win-win for everyone.     

           

What AP Didn’t Mention about Flossing

The recent flurry of news regarding the benefits of dental floss has left out an important point of view: while the evidence of flossing’s medical benefits may be weak, the evidence that it is pointless or harmful is even weaker. What’s more, flossing is an inexpensive oral hygiene practice accessible for people most in need of improved oral health.

But let’s break this down.

The Associated Press reported:

The evidence for flossing is "weak, very unreliable," of "very low" quality, and carries "a moderate to large potential for bias." … One study review in 2011 did credit floss with a slight reduction in gum inflammation — which can sometimes develop over time into full-fledged gum disease. However, the reviewers ranked the evidence as "very unreliable."

But the study review authors actually noted:

There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months.

What is important to note here is:

1. The "weak, unreliable" language actually references the evidence that flossing specifically reduces plaque, not gum disease. But more importantly, the language used comes from a different lexicon than we use every day. “Weak, unreliable, low quality” all sound like common terminology, but in the research world, this type of language doesn’t indicate the science shouldn’t be believed. The terms actually may reflect that study authors left out some details (such as the exact method of randomizing people) that the study reviewers could not confirm, not that the research is bad. 
2. The fact the review of studies could not prove plaque reduction at 1 and 3 months is very likely because tooth decay and gum disease are slow progressing issues that would require multi-year studies. It may also be because the standard for measuring plaque reduction only scores visible surfaces, so plaque may be reduced on non-visible surfaces such as directly between teeth.
3. In March 2015, the same study review linked above also determined: the very low evidence for the efficacy [of flossing], however, does not preclude the use of floss. For instance, in inter-dental situations that only allow for the penetration of a string of dental floss, floss is the best available tool.

When the U.S. government removed flossing from its 2015-2020 Dietary Guidelines, it did so because the strength of published studies regarding the effectiveness of flossing were admittedly weak, as the AP reports. The studies were generally short-term with a small number of participants due to the cost of running what constitutes high-quality clinical trials. 

Aside from cost, a clinical study comparing patients who did and did not floss would also mean exposing and even encouraging control group patients to worsen their oral health – and watch as it happens without intervention. In the research world, this is considered unethical. We don’t allow people to develop diseases as part of research, and that helps protect every patient in the United States.

According to dental experts including the DentaQuest Institute’s Dr. Brian Nový, Director of Practice Improvement, the lack of long-term clinical trials is also because there is already significant scientific evidence indicating how cavities form and how to prevent them.

Clinical trials don’t investigate how teeth decay, they examine new types of interventions. Oral health experts thus have relied on evidence extrapolated from shorter term studies as well as years of clinical experience and practice standards.

We know the easiest way to prevent cavities is to keep your mouth clean and minimize plaque, and that premise is incorporated into many clinical trials because it is accepted as standard oral hygiene practice. 

In one small study out of the University of North Carolina Chapel Hill, researchers randomized 119 adults who already had gum inflammation. After two weeks, they found the group that only brushed achieved a 35 percent reduction in bleeding sites between teeth, while the other groups who brushed and used floss achieved “dramatic reductions of about 67 percent” – almost double the improvement.

While small, this particular study correlates with the evidence dentists see every day among their patients – flossing creates a healthier mouth and less disease.

“The real problem is that the modern American diet is full of refined carbohydrates, which has changed the type of plaque that forms on our teeth,” Dr. Nový notes. “It is much stickier and more dangerous and everyone should want to keep it off their teeth if they want to avoid dental problems.” 

Tooth decay and gum disease can occur anywhere that food debris and plaque accumulate. The ideal spot is between teeth since it is difficult for the toothbrush bristles to remove or even attempt to remove any of the debris. That is why flossing or use of an inter-dental brush is recommended - to best remove the food debris that would remain between the gums and the teeth where a toothbrush cannot fit.

In response to the AP article, Dr. Robert Compton, Chief Dental Officer, DentaQuest and President, DentaQuest Institute, recalled an observation frequently used by health experts: the evidence to support the effectiveness of parachutes is weak because there has never been a double-blind randomized controlled trial to demonstrate effectiveness. That does not mean that parachutes are not effective. It just means no one has conducted expensive research that compared the effectiveness of somebody jumping with a parachute to a control group jumping without one.

“There's not enough money to conduct research for cancer cures and treatment for heart disease,” said Dr. Compton, adding, “if there isn’t funding for life-saving interventions, there will likely never be funding for the kind of research the AP reports would be required to sanction flossing as a recommended oral health habit.”

While flossing may be a habit that is difficult for people to connect with, it definitely helps remove food debris from hard-to-reach places. It is a low-cost, easy-to-use intervention that has the potential to improve the oral health of many, in particular those already suffering from dental disease.

This, among other reasons, is why oral health clinicians Tim Iafolla of the National Institutes of Health and Wayne Aldredge of the American Academy of Periodontology both told the AP they maintain flossing is important.

And Dr. Nový adds, “It comes down to personal hygiene. Do you want to have bad breath, and puffy bleeding gums, or do you want people to notice your smile because it’s healthy and attractive?  Flossing will improve many aspects of your life and no one has mentioned the research that shows male patients who don’t floss are more likely to experience erectile dysfunction...”  

Advocacy Efforts Encourage U.S. Treasury to Address Pediatric Dental

Earlier this month, the U.S. Department of Treasury released a proposed rule clarifying that pediatric dental benefits should be part of the calculation for marketplace tax credits. If implemented, this rule will be a major victory for low-income families in need of access to affordable dental coverage for their children.

Pediatric dental coverage is one of the 10 essential health benefits for marketplace plans that are subsidized based on income level under the Affordable Care Act (ACA).

Unfortunately, the cost of pediatric dental coverage is often not included in the total subsidy amount that roughly 85 percent of those purchasing coverage through the marketplace receive to help pay for the total cost of coverage for their family.

Without the full subsidy to cover all 10 essential health benefits promised under the ACA, many families struggle to get access to dental coverage for their children.

And Congress noticed.

A few months ago, Sen. Debbie Stabenow (D-Mich.) took the lead with a group of Senators who co-signed a letter urging the Treasury to make sure that the advanced premium tax credits under the ACA accounts for the cost of pediatric dental benefits.

The National Association of Dental Plans (NADP) and Delta Dental Plans Association (DDPA) led a coalition of organizations, including DentaQuest, to garner support for Sen. Stabenow’s efforts on this issue.

So, what’s changed for pediatric dental benefits?

The latest proposed rule ensures pediatric dental is included in the subsidy calculation for all families. 

Once finalized, this rule will mean that more families have the financial support they need to get the coverage they need to #ExpectOralHealth.

Industry advocates resoundingly supported the announcement. The American Dental Association (ADA), the Children’s Dental Health Project (CDHP), DDPA, and NADP released a joint press release applauding it.

And Sen. Stabenow said:

“For young children, early dental care is especially important, and this decision will help make dental coverage more affordable for families in Michigan and across the country.”

As policies aimed at improving access and affordability continue to evolve, it is equally critical that they are implemented effectively. We are pleased to see the Treasury Department taking steps to ensure that low-income children get access to the dental coverage they need to lead productive, healthy lives. 

As health care continues to undergo significant changes, oral health is too important to be forgotten. 

Oral Health Disparities between Men and Women

Did you know men are more likely to get oral cancer than women? Men are also more likely to skip dentist and doctor visits. For Men’s Health Month happening now, let’s raise awareness about these and other disparities.

Overall, more than 10 adults out of every 100,000 will develop oral cancer.

Oral cancer incidence among men is more than twice as high as among women in the United States. The same holds true when broken out by race for those who identified as white, American Indian/Alaska Native, and Asian or Pacific Islander.

However, prevalence among black men is more than three times as high as among black women. The disparity is similar among Hispanic men and women, too.

What’s more, oral cancer rates increase with age among both women and men. The increase becomes more rapid after age 50 and peaks between ages 60 and 70.

But diagnosing oral cancer at an early stage significantly increases five-year survival rates. Today, we are more aware of the importance of oral health and how to prevent disease thanks in large part to better education, greater access and advances in technology.

These factors have helped oral cancer survival rates steadily improve since 1975, though the disparity among white and black men has remained largely unchanged.

So what more can be done to reduce oral health disparities?

To start, efforts like those funded by the DentaQuest Foundation are designed to target prevention and collaboration in hyper-local ways.

One investment supports the Chicago Community Oral Health Forum to develop and expand school-based oral health education to students in the Chicago Public School system and the development of dental homes for students with urgent needs.

Another investment is supporting the University of Alabama as it implements a framework for interprofessional training that will produce health care practitioners in Alabama with a greater understanding of oral health and the ability to work in health teams to provide optimal care to their patients – from geriatrics to pediatrics.

These types of programs happening across the country target long-term improvements and sustainable changes for a variety of communities – from predominantly black public schools in Chicago to the elderly in Alabama.

The DentaQuest Institute, meanwhile, is expanding oral health care to rural parts of the country. Experts are working closely with local teams, helping providers develop evidence-based and financially-sound practices that ensure a continuum of care for regions that largely have been without regular access to dental care.

With dedication and support, these projects can ultimately change the trajectory of oral health disparities in America.