AJPH POLICY
Accountable Care Organizations and Oral Health Accountability Accountable care organizations agree to be accountable for the cost and outcomes of an attributed population. However, in many, no provisions have been made to account for oral health. There are several social, medical, and financial implications for health care provider and payer systems and health care outcomes when oral health is not accounted for in patient management. How can an organization strive to improve population health without including the oral health system? Total systemic health for a population must include oral health. Accountable care organizations are positioned to change the course of oral health in the United States and close the disparities that exist among vulnerable populations, including seniors. Such efforts will reduce health care costs. Opportunities abound to expand points of entry into the health care system via dental or medical care. Closing the great divide between 2 historically isolated professions will position the United States to make gains in true population health. I provide evidence of the need to mandate access to oral health care services for all Americans—specifically adults, because legislation currently exists for pediatric dental coverage. (Am J Public Health. 2017;107:S61–S64. doi:10.2105/ AJPH.2017.303833)
Supplement 1, 2017, Vol 107, No. S1
Melanie E. Mayberry, DDS, MS-HCM
A
n accountable care organization (ACO) is an integrated health care delivery system that contracts to provide a full continuum of services to a defined population.1 Since the inception of the Patient Protection and Affordable Care Act (ACA) in 2010 more than 750 ACOs have been established.2 Each is required to provide primary care services to an attributed population of at least 5000 traditional fee-for-service beneficiaries for a contract period of at least 3 years.1 The goal of ACOs, which consist of physicians and hospitals, is to improve the quality of health, health outcomes, and health care spending among its attributed group. Each is incentivized to improve health and lower health care costs. If improvements are noted in these areas then financial rewards will be given to the respective physicians and hospitals.3 A key component of ACOs is to “facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs.”3(p1) However, most ACOs give no consideration to the inclusion or coordination of oral health care. This paradigm continues to promote disconnection of the mouth from the body. In no way can disjointed systems provide quality total health or reduced health care costs. Dental disease affects people in all walks of life. In 2000, the
AJPH
surgeon general referred to oral disease as a “silent epidemic” and said that oral health is essential to general health.4 Dental disease is among the great preventable public health challenges of the 21st century.4 Considered a chronic health condition, it ranks high in prevalence, according to the US surgeon general.4 It especially affects seniors, children, adolescents, low-income people, minorities, and people with special health care needs.4 Seniors’ dental problems are compounded by chronic conditions associated with aging, including the prescribing of more than 400 common medications that cause xerostomia and increase the risk of oral disease.5 Oral health includes the mouth and its associated structures, with each having the potential to be plagued by disease and pathology. Dental caries, periodontal disease, oral and facial pain, and oral cancer are some of the sequelae of oral disease. Such conditions impact hospitalizations for respiratory disease and affect cardiovascular health, glycemic control in diabetes, perinatal health, preterm birth, and infant mortality.6–9 Because all systems within the human body are interconnected,
poor oral health’s role in different systemic disorders has been widely documented. A negative impact in one area may negatively affect another area, with inflammation being the key component. Inflammation links periodontal disease and other oral disease to systemic disorders such as cardiovascular disease and diabetes.6 Although aging may not be a commonly accepted risk factor, a higher prevalence of periodontal disease, cardiovascular disease, diabetes, and caries is seen in the adult population. Twenty-three percent of seniors aged 65 years and older have untreated dental decay,10 and 39% are at risk for periodontal disease.6 This is a significant portion of the population that may be assigned to ACOs for the management of health, costs, and health care outcomes with no provisions for addressing oral health. Although Medicare covers hospitalizations, physician outpatient visits, and prescription medicines, it does not provide comprehensive dental coverage, including treatment of caries and periodontal disease.11 A 1980 study by Simonka et al. documented that patients with myocardial infarction had
ABOUT THE AUTHOR Melanie E. Mayberry is with the Department of Oral Health and Integrated Care, University of Detroit Mercy School of Dentistry, Detroit, MI. Correspondence should be sent to Melanie E. Mayberry, DDS, MS-HCM, Chair, Department of Oral Health and Integrated Care, University of Detroit Mercy, School of Dentistry, 2700 Martin Luther King Jr. Blvd., Detroit, MI 48208 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted April 5, 2017. doi: 10.2105/AJPH.2017.303833
Mayberry
Peer Reviewed
Public Health Policy
S61
AJPH POLICY
a higher prevalence of periodontal disease,6 a chronic inflammatory disease. Chronic inflammation is the etiological factor identified as one of the links between poor oral health’s impact on other systemic diseases. In cardiovascular disease, it affects the endothelial function. In diabetes, it affects the metabolic control, specifically the impact of inflammatory mediators on cellular insulin receptors.6 In some cases, diabetic patients with periodontitis are 6 times more at risk for worsening glycemic control and other diabetic health complications.7 Although socioeconomic factors must also be considered with many medical diagnosis and comorbidities, there are well established medical–scientific factors involved in the association of oral health with cardiovascular disease and oral health with diabetes. The medical–scientific explanation is that poor oral health negatively affects insulin action and can reduce glucose uptake by skeletal muscles, which gives rise to insulin resistance.6 This affects health care spending for one of the nation’s leading chronic diseases. Patients with diabetes, cardiovascular disease, cerebral vascular disease, and rheumatoid arthritis and pregnant patients had lower medical costs and hospitalizations in times following periodontal treatment than did patients who did not receive this care.8 There is also evidence linking periodontal disease to preterm birth.8 In 1 study of 31 published studies, 22 showed a positive association between premature birth and periodontal disease,12 whereas 9 studies, none including randomized clinical trials, did not show a positive association.12 It has been noted that although the association has been well established, periodontal intervention during pregnancy
S62
Public Health Policy
has not consistently resulted in reductions in preterm birth and low birth weight.13,14 Some studies suggest that periodontal intervention before pregnancy may demonstrate more reduction of adverse pregnancy outcomes.13,14 Poor oral health also has financial implications. The medical and dental claims of 30,000 members tracked by Cigna (a global health insurance company) demonstrated a 28% reduction in annual medical costs among diabetic patients who received appropriate periodontal treatment for 3 years. Similar reductions in annual medical costs, 25% and 35%, respectively, were also noted among patients with heart disease and stroke history who received periodontal treatment.15 Aetna insurance has conducted similar studies yielding similar results. Poor oral health also financially affects emergency department (ED) visits because substantial hospital resources are spent treating dental conditions in the ED.16 Between 2008 and 2010, an extensive nationwide study examined visits made to the ED for dental conditions. The study documented that 8.0% were covered by Medicare, 30.0% were covered by Medicaid, and 40.5% were uninsured. The mean ED charges were $760.00, and the total ED charges across the entire United States during the 3-year study was $2.7 billion.16 This demonstrates how expensive care is rendered without definitively resolving patient pain, infection, or oral disease. Patients leave with the offending tooth or oral disease still present, requiring them to see an oral health care provider. Most ED patients who have a dental diagnosis are generally dismissed with antibiotic and analgesic prescriptions. At $760 per visit
Peer Reviewed
Mayberry
and an average of $1 billion spent in the United States to treat these conditions,16 this is not only costly care but also the wrong care at the wrong place. Dental disease also has social and educational ramifications. In young people, certain oral disease conditions may lead to functional limitations.17 Poor oral health has been shown to result in decreased academic performance and to affect behavioral and social development. More than 51 million school hours are lost each year because of dental problems.7,18,19 Toothaches negatively affect nutritional intake, speaking, and social interactions. Natural teeth retention enhances quality of life and may facilitate longevity. There is an association between tooth loss and mortality.20 Many uninsured people in the United States have untreated oral pain, infection, and oral disease as evident in ED and certain free clinics’ patient utilization rates in the United States.21–24 Poor dental health also carries social stigma. Dental disease causes halitosis, which may lead to negative social interactions.25 In addition, research has shown that certain emotional conditions are associated with low oral health–related quality of life measures, including reduced mental health.26,27 In elderly persons with disabilities, relatively poor cognitive states have been noted. Research has also shown that cognitive function can be negatively affected by tooth loss and periodontal disease.26 Poor oral health is also a national security concern. The US Department of Defense documented that 52% of new recruits were in need of urgent dental treatment that would delay their deployment.28 ACOs have a vested interest in improving oral health care
AJPH
for their patients through collaboration, coordination, and integrated care efforts. Historically, medicine and dentistry systems have practiced in isolated silos. Collaboration, coordination, colocation, and integration would increase access and expand points of entry into each system. Much of the ACO population are Medicare beneficiaries. Medicare does not provide oral health benefits. Lack of oral health care and access negatively affects the medical conditions being managed by ACOs. Not only does this affect quality metrics, it also affects quality of life. The ACA mandates pediatric dental services as one of 10 “essential health benefits.” As such, states must offer it in a health plan in the marketplace. However, no mandate exists for adult oral health care. In fact, some states offer no adult Medicaid coverage for dental services. Very few offer expanded dental services for adult Medicaid. These offerings are perennially at the mercy of state budgets. There has been a burgeoning of pediatric dental programs that have improved access and receipt of dental care. However, any traction gained will be eroded in the adult years if no coverage exists to encourage prevention or maintain health established between birth and young adulthood. The “triple aim” of the ACA is to lower health care costs, improve access, and improve quality and outcomes. As long as initiatives lack inclusion of adult oral health, opportunities will be lost for improved disease and prevention management. Current legislation does not meet these goals. Mandates that do not include oral health access provisions across the life cycle and parlay it as a quality
Supplement 1, 2017, Vol 107, No. S1
AJPH POLICY
metric will result in little footing gained in medical–dental coordination, reduced spending on ED visits for dental diagnosis, and improvements in cardiovascular, pregnancy, and diabetic management. Twenty million people have gained medical health insurance coverage because of the ACA.29 However, this does not include dental coverage. Only 4.5 million adults will gain meaningful dental coverage via Medicaid.30 Not every state will expand Medicaid dental coverage for adults. States offer 1 of 4 tiers for adult Medicaid dental coverage: no coverage, emergency-only coverage, limited coverage, and extensive coverage (meaningful coverage).31 As of January 1, 2017, 31 states and the District of Columbia have expanded Medicaid.32 States are not required to cover adult dental benefits under Medicaid insurance and Medicare insurance does not provide dental coverage. Of the 50 states, 5 provide no adult Medicaid dental coverage, 26 provide emergency-only or limited coverage, and only 14 provide extensive, meaningful adult dental coverage.31 The ACA has provided no impetus to change this alarming fact. For ACOs to achieve maximum reach and influence on health care costs and improved outcomes, not only do they have to reduce leakage of specialty services outside their organization,33 but they also have to incorporate oral health assessments, oral health literacy, and oral health management into the overall management of their attributed population. The ACA legislation and Institutes of Medicine seek to meet the “triple aim.” To do so, the ACA must be amended to include adult oral health services as an essential health benefit. Future
Supplement 1, 2017, Vol 107, No. S1
policies may also consider the role of genomics on predictive, personalized, and preventive care.34 Mandating dental care access for populations that are attributed to ACOs will reduce health care costs of long-term management. Oral disease addressed early through management and prevention will reduce the long-term financial burden on total health and total health care expenditures. Prevention is far cheaper than is the treatment of chronic disease or acute episodes of chronic neglect.35 EDs nationwide face unnecessary burdens on time, resources, and management costs for patients that use EDs to seek oral health care.36 There is ample medical, social, and scientific evidence outlining the effect of oral health on total health. Major medical insurance carriers have conducted their own claims studies, which underscore the financial toll untreated oral disease takes on systemic health and outcomes. Congress recognizes the value of oral health, as seen in the ACA, which lists oral health care services for pediatric patients as an essential health benefit and the need for such legislation for pediatric patients. Tooth decay is one of the most common chronic childhood diseases. It is 5 times more common than is asthma37 and it has a significant impact on the well-being of children. The irony is that there is also published evidence of the negative impact of oral disease on adults; provisions in the ACA and ACO policies have not been extended to adults. Between 2000 and 2014, 62% of patients aged 65 years and older did not have dental insurance.38 Close to 50% of adults have periodontal disease39 and more than 90% have tooth decay.35 Washington policymakers
AJPH
must recognize the value of oral health care for adults and pass legislation that mandates equitable health care initiatives for adults as they have done for children. Now is the time for ACOs to include oral health services for their population and recognize that oral health is essential to total health. Although there are a few ACOs offering dental services— including the Atrius Health Pioneer in Massachusetts, the North Texas ACO in Texas, Mount Sinai Care in New York, and a coordinated care organization in Oregon—considering that there are more than 700 ACOs, this is a less than favorable inclusion of dental services for the population. However, the coordinated care organizations are specifically required to have formal contractual relationships with dental care organizations that serve its members.40 Such models recognize the essentiality of oral health for total quality health and are strategically positioned to manage health care costs and improve health outcomes. These may be the beacons of light that ACOs need to follow. ACOs are well positioned to change the course of oral health in the United States and close the gaps that exist among vulnerable populations, including seniors. Opportunities abound to expand points of entry into the health care system via dental or medical care. Closing the great divide between 2 historically isolated professions will position the United States to make gains in true population health. ACKNOWLEDGMENTS I wish to thank Maria A. Manautou, DDS, and Jeffrey Levin-Scherz, MD, MBA, for their comments on earlier drafts of the essay.
REFERENCES 1. DiFiore M. Accountable care organizations: what you need to know. J Am Coll Radiol. 2014;11(6):623–624.
Mayberry
2. Shortell S, Addicott R, Walsh N, Ham C. The NHS five year forward view: lessons from the United States in developing new care models. BMJ. 2015; 350:h2005. 3. MacKinney AC, Mueller KJ, Zhu X, et al. Medicare accountable care organizations: program eligibility, beneficiary assignment, and quality measures. Brief no. 2014-3. 2014. Available at: https:// www.public-health.uiowa.edu/rupri/ publications/policybriefs/2014/ACO% 20Eligibiilty%20Assignment.pdf. Accessed April 27, 2016. 4. Institute of Medicine of the National Academies. Advancing oral health in America. 2001. Available at: https:// www.in.gov/isdh/files/Advancing_ Oral_Health_2011_Report_Brief.pdf. Accessed March 20, 2015. 5. Flink H, Bergdahl M, Tegelberg A, Rosenblad A, Lagerlof ¨ F. Prevalence of hyposalivation in relation to general health, body mass index and remaining teeth in different age groups of adults. Community Dent Oral Epidemiol. 2008; 36(6):523–531. 6. Carramolino-Cuéllar E, Tomás I, Jiménez-Soriano Y. Relationship between the oral cavity and cardiovascular diseases and metabolic syndrome. Med Oral Patol Oral Cir Bucal. 2014;19(3): e289–e294. 7. Grantmakers in Health. Returning the mouth to the body: integrating oral health and primary care. Available at: http:// www.gih.org/files/FileDownloads/ Returning_the_Mouth_to_the_Body_ no40_September_2012.pdf. Accessed February 28, 2015. 8. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum JJ. Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions. Am J Prev Med. 2014; 47(2):166–174. 9. Fernández-Plata R, Olmedo-Torres D, Martínez-Briseño D, García-Sancho C, Franco-Marina F, González-Cruz H. [Prevalence of severe periodontal disease and its association with respiratory disease in hospitalized adult patients in a tertiary care center]. Gac Med Mex. 2015;151(5): 608–613. 10. National Institute of Dental and Craniofacial Research. Data and statistics. 2012. Available at: http://www.nidcr. nih.gov/DataStatistics. Accessed February 28, 2015. 11. Medicare.Gov. Your Medicare coverage: dental services. Available at: https://www.medicare.gov/coverage/ dental-services.html. Accessed December 3, 2016. 12. Clothier B, Stringer M, Jeffcoat MK. Periodontal disease and pregnancy outcomes: exposure, risk and intervention. Best Pract Res Clin Obstet Gynaecol. 2007; 21(3):451–466.
Peer Reviewed
Public Health Policy
S63
AJPH POLICY
13. Xiong X, Buckens P, Goldenberg RL, Offenbacher S, Qian X. Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy? Am J Obstet Gynecol. 2011;205(2):111e1–111e6.
26. Jensen PM, Saunders RL, Thierer T, Friedman B. Factors associated with oral health–related quality of life in community-dwelling elderly persons with disabilities. J Am Geriatr Soc. 2008;56(4): 711–717.
38. Nasseh K, Vujicic M. Dental benefits coverage increased for working-age adults in 2014. 2016. Available at: http://www. ada.org/~/media/ADA/Science and Research/HPI/Files/HPIBrief_1016_2. pdf. Accessed December 3, 2016.
14. Offenbacher S, Beck JD. Commentary: changing paradigms in the oral disease–systemic disease relationship. J Periodontol. 2014;85(6):761–764.
27. Sischo L, Broder HL. Oral healthrelated quality of life: what, why, how, and future implications. J Dent Res. 2011; 90(11):1264–1270.
39. Eke PI, Dye BA, Wei L, et al. Update on prevalence of periodontitis in adults in the United States: NHANES 2009 to 2012. J Periodontol. 2015;86(5):611–622.
15. Cigna. Improved health and lower medical costs: why good dental care is important. 2013. Available at: https:// www.cigna.com/assets/docs/life-walllibrary/Whygooddentalcareisimportant_ whitepaper.pdf. Accessed March 20, 2015.
28. Leiendecker TM, Martin G, Moss DL. 2008 Department of Defense (DoD) recruit oral health survey. Mil Med. 2011; 176(8 suppl):1–44.
40. Vujicic M, Nasseh K. Accountable care organizations present key opportunities for the dental profession. 2013.
16. Allareddy V, Rampa S, Lee MK, Allareddy V, Nalliah RP. Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. J Am Dent Assoc. 2014;145(4):331–337. 17. Clementino MA, Pinto-Sarmento TC, Costa EM, Martins CC, GranvilleGarcia AF, Paiva SM. Association between oral conditions and functional limitations in childhood. J Oral Rehabil. 2015;42(6):420–429. 18. Pew Center on the States. The state of children’s dental health: making coverage matter. 2011. Available at: http://www. pewtrusts.org/~/media/legacy/uploadedfiles/ wwwpewtrustsorg/reports/state_policy/ childrensdental50statereport2011pdf.pdf? la=en. Accessed February 28, 2015. 19. Oral Health in America: A Report of the Surgeon General. US Department of Health and Human Services: Rockville, MD; 2000.
29. US Department of Health and Human Services. 20 million people have gained health insurance coverage because of the Affordable Care Act, new estimates show. 2016. Available at: https://www.hhs.gov/ about/news/2016/03/03/20-millionpeople-have-gained-health-insurancecoverage-because-affordable-care-actnew-estimates. Accessed January 29, 2017. 30. Nasseh K, Vujicic M, O’Dell A. Affordable Care Act expands dental benefits for children but does not address critical access to dental care issues. 2013. Available at: http://www.ada.org/~/media/ADA/ Science%20and%20Research/Files/ HPRCBrief_0413_3.pdf. Accessed December 3, 2016. 31. Vestal C. Adult dental coverage expanding slowly in Medicaid. 2015. Available at: http://www.pewtrusts.org/ en/research-and-analysis/blogs/stateline/ 2015/6/10/adult-dental-coverageexpanding-slowly-in-medicaid. Accessed December 3, 2016.
20. Hirotomi T, Yoshihara A, Ogawa H, Miyazaki H. Number of teeth and 5-year mortality in an elderly population. Community Dent Oral Epidemiol. 2015;43(3): 226–231.
32. Henry J Kaiser Family Foundation. Status of state action on the Medicaid expansion decision. Available at: http:// kff.org/health-reform/state-indicator/ state-activity-around-expandingmedicaid-under-the-affordable-care-act/ ?currentTimeframe=0. Accessed December 3, 2016.
21. Zabos GP, Northridge M, Ro M, Trinh C, Vaughn R, Moon J. Lack of oral health care for adults in Harlem: a hidden crisis. Am J Public Health. 2008;98(9 suppl): S102–S105.
33. McWilliams JM, Chernew ME, Dalton JB, Landon BE. Outpatient care patterns and organizational accountability in Medicare. JAMA Intern Med. 2014; 174(6):938–945.
22. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a national perspective. Ann Emerg Med. 2003;42(1):93–99.
34. Carlson RJ. Preemptive public policy for genomics. J Health Polit Policy Law. 2008;33(1):39–51.
23. Davis EE, Deinard AS, Ma¨ıga EW. Doctor, my tooth hurts: the costs of incomplete dental care in the emergency room. J Public Health Dent. 2010;70(3): 205–210. 24. Lee HH, Lewis C, Saltzman B, Starks H. Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008. Am J Public Health. 2012; 102(11):e77–e83. 25. Rayman S, Almas K. Halitosis among racially diverse populations: an update. Int J Dent Hyg. 2008;6(1):2–7.
S64
Public Health Policy
Available at: http://www.ada.org/ ~/media/ADA/Science and Research/ HPI/Files/HPIBrief_0413_2.ashx. Accessed February 28, 2015.
35. The Power of Prevention: Chronic Disease... The Public Health Challenge of the 21st Century. Centers for Disease Control and Prevention: Atlanta, GA; 2009. 36. Sun BC, Chi DL, Schwarz E, et al. Emergency department visits for nontraumatic dental problems: a mixedmethods study. Am J Public Health. 2015; 105(5):947–955. 37. American Academy of Pediatric Dentistry. Early Childhood Caries (ECC). Available at: http://www. mychildrensteeth.org/assets/2/7/ ECCstats.pdf. Accessed January 29, 2017.
Peer Reviewed
Mayberry
AJPH
Supplement 1, 2017, Vol 107, No. S1
Accountable Care Organizations and Oral Health Accountability Accountable care organizations agree to be accountable for the cost and outcomes of an attributed population. However, in many, no provisions have been made to account for oral health. There are several social, medical, and financial implications for health care provider and payer systems and health care outcomes when oral health is not accounted for in patient management. How can an organization strive to improve population health without including the oral health system? Total systemic health for a population must include oral health. Accountable care organizations are positioned to change the course of oral health in the United States and close the disparities that exist among vulnerable populations, including seniors. Such efforts will reduce health care costs. Opportunities abound to expand points of entry into the health care system via dental or medical care. Closing the great divide between 2 historically isolated professions will position the United States to make gains in true population health. I provide evidence of the need to mandate access to oral health care services for all Americans—specifically adults, because legislation currently exists for pediatric dental coverage. (Am J Public Health. 2017;107:S61–S64. doi:10.2105/ AJPH.2017.303833)
Supplement 1, 2017, Vol 107, No. S1
Melanie E. Mayberry, DDS, MS-HCM
A
n accountable care organization (ACO) is an integrated health care delivery system that contracts to provide a full continuum of services to a defined population.1 Since the inception of the Patient Protection and Affordable Care Act (ACA) in 2010 more than 750 ACOs have been established.2 Each is required to provide primary care services to an attributed population of at least 5000 traditional fee-for-service beneficiaries for a contract period of at least 3 years.1 The goal of ACOs, which consist of physicians and hospitals, is to improve the quality of health, health outcomes, and health care spending among its attributed group. Each is incentivized to improve health and lower health care costs. If improvements are noted in these areas then financial rewards will be given to the respective physicians and hospitals.3 A key component of ACOs is to “facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs.”3(p1) However, most ACOs give no consideration to the inclusion or coordination of oral health care. This paradigm continues to promote disconnection of the mouth from the body. In no way can disjointed systems provide quality total health or reduced health care costs. Dental disease affects people in all walks of life. In 2000, the
AJPH
surgeon general referred to oral disease as a “silent epidemic” and said that oral health is essential to general health.4 Dental disease is among the great preventable public health challenges of the 21st century.4 Considered a chronic health condition, it ranks high in prevalence, according to the US surgeon general.4 It especially affects seniors, children, adolescents, low-income people, minorities, and people with special health care needs.4 Seniors’ dental problems are compounded by chronic conditions associated with aging, including the prescribing of more than 400 common medications that cause xerostomia and increase the risk of oral disease.5 Oral health includes the mouth and its associated structures, with each having the potential to be plagued by disease and pathology. Dental caries, periodontal disease, oral and facial pain, and oral cancer are some of the sequelae of oral disease. Such conditions impact hospitalizations for respiratory disease and affect cardiovascular health, glycemic control in diabetes, perinatal health, preterm birth, and infant mortality.6–9 Because all systems within the human body are interconnected,
poor oral health’s role in different systemic disorders has been widely documented. A negative impact in one area may negatively affect another area, with inflammation being the key component. Inflammation links periodontal disease and other oral disease to systemic disorders such as cardiovascular disease and diabetes.6 Although aging may not be a commonly accepted risk factor, a higher prevalence of periodontal disease, cardiovascular disease, diabetes, and caries is seen in the adult population. Twenty-three percent of seniors aged 65 years and older have untreated dental decay,10 and 39% are at risk for periodontal disease.6 This is a significant portion of the population that may be assigned to ACOs for the management of health, costs, and health care outcomes with no provisions for addressing oral health. Although Medicare covers hospitalizations, physician outpatient visits, and prescription medicines, it does not provide comprehensive dental coverage, including treatment of caries and periodontal disease.11 A 1980 study by Simonka et al. documented that patients with myocardial infarction had
ABOUT THE AUTHOR Melanie E. Mayberry is with the Department of Oral Health and Integrated Care, University of Detroit Mercy School of Dentistry, Detroit, MI. Correspondence should be sent to Melanie E. Mayberry, DDS, MS-HCM, Chair, Department of Oral Health and Integrated Care, University of Detroit Mercy, School of Dentistry, 2700 Martin Luther King Jr. Blvd., Detroit, MI 48208 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted April 5, 2017. doi: 10.2105/AJPH.2017.303833
Mayberry
Peer Reviewed
Public Health Policy
S61
AJPH POLICY
a higher prevalence of periodontal disease,6 a chronic inflammatory disease. Chronic inflammation is the etiological factor identified as one of the links between poor oral health’s impact on other systemic diseases. In cardiovascular disease, it affects the endothelial function. In diabetes, it affects the metabolic control, specifically the impact of inflammatory mediators on cellular insulin receptors.6 In some cases, diabetic patients with periodontitis are 6 times more at risk for worsening glycemic control and other diabetic health complications.7 Although socioeconomic factors must also be considered with many medical diagnosis and comorbidities, there are well established medical–scientific factors involved in the association of oral health with cardiovascular disease and oral health with diabetes. The medical–scientific explanation is that poor oral health negatively affects insulin action and can reduce glucose uptake by skeletal muscles, which gives rise to insulin resistance.6 This affects health care spending for one of the nation’s leading chronic diseases. Patients with diabetes, cardiovascular disease, cerebral vascular disease, and rheumatoid arthritis and pregnant patients had lower medical costs and hospitalizations in times following periodontal treatment than did patients who did not receive this care.8 There is also evidence linking periodontal disease to preterm birth.8 In 1 study of 31 published studies, 22 showed a positive association between premature birth and periodontal disease,12 whereas 9 studies, none including randomized clinical trials, did not show a positive association.12 It has been noted that although the association has been well established, periodontal intervention during pregnancy
S62
Public Health Policy
has not consistently resulted in reductions in preterm birth and low birth weight.13,14 Some studies suggest that periodontal intervention before pregnancy may demonstrate more reduction of adverse pregnancy outcomes.13,14 Poor oral health also has financial implications. The medical and dental claims of 30,000 members tracked by Cigna (a global health insurance company) demonstrated a 28% reduction in annual medical costs among diabetic patients who received appropriate periodontal treatment for 3 years. Similar reductions in annual medical costs, 25% and 35%, respectively, were also noted among patients with heart disease and stroke history who received periodontal treatment.15 Aetna insurance has conducted similar studies yielding similar results. Poor oral health also financially affects emergency department (ED) visits because substantial hospital resources are spent treating dental conditions in the ED.16 Between 2008 and 2010, an extensive nationwide study examined visits made to the ED for dental conditions. The study documented that 8.0% were covered by Medicare, 30.0% were covered by Medicaid, and 40.5% were uninsured. The mean ED charges were $760.00, and the total ED charges across the entire United States during the 3-year study was $2.7 billion.16 This demonstrates how expensive care is rendered without definitively resolving patient pain, infection, or oral disease. Patients leave with the offending tooth or oral disease still present, requiring them to see an oral health care provider. Most ED patients who have a dental diagnosis are generally dismissed with antibiotic and analgesic prescriptions. At $760 per visit
Peer Reviewed
Mayberry
and an average of $1 billion spent in the United States to treat these conditions,16 this is not only costly care but also the wrong care at the wrong place. Dental disease also has social and educational ramifications. In young people, certain oral disease conditions may lead to functional limitations.17 Poor oral health has been shown to result in decreased academic performance and to affect behavioral and social development. More than 51 million school hours are lost each year because of dental problems.7,18,19 Toothaches negatively affect nutritional intake, speaking, and social interactions. Natural teeth retention enhances quality of life and may facilitate longevity. There is an association between tooth loss and mortality.20 Many uninsured people in the United States have untreated oral pain, infection, and oral disease as evident in ED and certain free clinics’ patient utilization rates in the United States.21–24 Poor dental health also carries social stigma. Dental disease causes halitosis, which may lead to negative social interactions.25 In addition, research has shown that certain emotional conditions are associated with low oral health–related quality of life measures, including reduced mental health.26,27 In elderly persons with disabilities, relatively poor cognitive states have been noted. Research has also shown that cognitive function can be negatively affected by tooth loss and periodontal disease.26 Poor oral health is also a national security concern. The US Department of Defense documented that 52% of new recruits were in need of urgent dental treatment that would delay their deployment.28 ACOs have a vested interest in improving oral health care
AJPH
for their patients through collaboration, coordination, and integrated care efforts. Historically, medicine and dentistry systems have practiced in isolated silos. Collaboration, coordination, colocation, and integration would increase access and expand points of entry into each system. Much of the ACO population are Medicare beneficiaries. Medicare does not provide oral health benefits. Lack of oral health care and access negatively affects the medical conditions being managed by ACOs. Not only does this affect quality metrics, it also affects quality of life. The ACA mandates pediatric dental services as one of 10 “essential health benefits.” As such, states must offer it in a health plan in the marketplace. However, no mandate exists for adult oral health care. In fact, some states offer no adult Medicaid coverage for dental services. Very few offer expanded dental services for adult Medicaid. These offerings are perennially at the mercy of state budgets. There has been a burgeoning of pediatric dental programs that have improved access and receipt of dental care. However, any traction gained will be eroded in the adult years if no coverage exists to encourage prevention or maintain health established between birth and young adulthood. The “triple aim” of the ACA is to lower health care costs, improve access, and improve quality and outcomes. As long as initiatives lack inclusion of adult oral health, opportunities will be lost for improved disease and prevention management. Current legislation does not meet these goals. Mandates that do not include oral health access provisions across the life cycle and parlay it as a quality
Supplement 1, 2017, Vol 107, No. S1
AJPH POLICY
metric will result in little footing gained in medical–dental coordination, reduced spending on ED visits for dental diagnosis, and improvements in cardiovascular, pregnancy, and diabetic management. Twenty million people have gained medical health insurance coverage because of the ACA.29 However, this does not include dental coverage. Only 4.5 million adults will gain meaningful dental coverage via Medicaid.30 Not every state will expand Medicaid dental coverage for adults. States offer 1 of 4 tiers for adult Medicaid dental coverage: no coverage, emergency-only coverage, limited coverage, and extensive coverage (meaningful coverage).31 As of January 1, 2017, 31 states and the District of Columbia have expanded Medicaid.32 States are not required to cover adult dental benefits under Medicaid insurance and Medicare insurance does not provide dental coverage. Of the 50 states, 5 provide no adult Medicaid dental coverage, 26 provide emergency-only or limited coverage, and only 14 provide extensive, meaningful adult dental coverage.31 The ACA has provided no impetus to change this alarming fact. For ACOs to achieve maximum reach and influence on health care costs and improved outcomes, not only do they have to reduce leakage of specialty services outside their organization,33 but they also have to incorporate oral health assessments, oral health literacy, and oral health management into the overall management of their attributed population. The ACA legislation and Institutes of Medicine seek to meet the “triple aim.” To do so, the ACA must be amended to include adult oral health services as an essential health benefit. Future
Supplement 1, 2017, Vol 107, No. S1
policies may also consider the role of genomics on predictive, personalized, and preventive care.34 Mandating dental care access for populations that are attributed to ACOs will reduce health care costs of long-term management. Oral disease addressed early through management and prevention will reduce the long-term financial burden on total health and total health care expenditures. Prevention is far cheaper than is the treatment of chronic disease or acute episodes of chronic neglect.35 EDs nationwide face unnecessary burdens on time, resources, and management costs for patients that use EDs to seek oral health care.36 There is ample medical, social, and scientific evidence outlining the effect of oral health on total health. Major medical insurance carriers have conducted their own claims studies, which underscore the financial toll untreated oral disease takes on systemic health and outcomes. Congress recognizes the value of oral health, as seen in the ACA, which lists oral health care services for pediatric patients as an essential health benefit and the need for such legislation for pediatric patients. Tooth decay is one of the most common chronic childhood diseases. It is 5 times more common than is asthma37 and it has a significant impact on the well-being of children. The irony is that there is also published evidence of the negative impact of oral disease on adults; provisions in the ACA and ACO policies have not been extended to adults. Between 2000 and 2014, 62% of patients aged 65 years and older did not have dental insurance.38 Close to 50% of adults have periodontal disease39 and more than 90% have tooth decay.35 Washington policymakers
AJPH
must recognize the value of oral health care for adults and pass legislation that mandates equitable health care initiatives for adults as they have done for children. Now is the time for ACOs to include oral health services for their population and recognize that oral health is essential to total health. Although there are a few ACOs offering dental services— including the Atrius Health Pioneer in Massachusetts, the North Texas ACO in Texas, Mount Sinai Care in New York, and a coordinated care organization in Oregon—considering that there are more than 700 ACOs, this is a less than favorable inclusion of dental services for the population. However, the coordinated care organizations are specifically required to have formal contractual relationships with dental care organizations that serve its members.40 Such models recognize the essentiality of oral health for total quality health and are strategically positioned to manage health care costs and improve health outcomes. These may be the beacons of light that ACOs need to follow. ACOs are well positioned to change the course of oral health in the United States and close the gaps that exist among vulnerable populations, including seniors. Opportunities abound to expand points of entry into the health care system via dental or medical care. Closing the great divide between 2 historically isolated professions will position the United States to make gains in true population health. ACKNOWLEDGMENTS I wish to thank Maria A. Manautou, DDS, and Jeffrey Levin-Scherz, MD, MBA, for their comments on earlier drafts of the essay.
REFERENCES 1. DiFiore M. Accountable care organizations: what you need to know. J Am Coll Radiol. 2014;11(6):623–624.
Mayberry
2. Shortell S, Addicott R, Walsh N, Ham C. The NHS five year forward view: lessons from the United States in developing new care models. BMJ. 2015; 350:h2005. 3. MacKinney AC, Mueller KJ, Zhu X, et al. Medicare accountable care organizations: program eligibility, beneficiary assignment, and quality measures. Brief no. 2014-3. 2014. Available at: https:// www.public-health.uiowa.edu/rupri/ publications/policybriefs/2014/ACO% 20Eligibiilty%20Assignment.pdf. Accessed April 27, 2016. 4. Institute of Medicine of the National Academies. Advancing oral health in America. 2001. Available at: https:// www.in.gov/isdh/files/Advancing_ Oral_Health_2011_Report_Brief.pdf. Accessed March 20, 2015. 5. Flink H, Bergdahl M, Tegelberg A, Rosenblad A, Lagerlof ¨ F. Prevalence of hyposalivation in relation to general health, body mass index and remaining teeth in different age groups of adults. Community Dent Oral Epidemiol. 2008; 36(6):523–531. 6. Carramolino-Cuéllar E, Tomás I, Jiménez-Soriano Y. Relationship between the oral cavity and cardiovascular diseases and metabolic syndrome. Med Oral Patol Oral Cir Bucal. 2014;19(3): e289–e294. 7. Grantmakers in Health. Returning the mouth to the body: integrating oral health and primary care. Available at: http:// www.gih.org/files/FileDownloads/ Returning_the_Mouth_to_the_Body_ no40_September_2012.pdf. Accessed February 28, 2015. 8. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum JJ. Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions. Am J Prev Med. 2014; 47(2):166–174. 9. Fernández-Plata R, Olmedo-Torres D, Martínez-Briseño D, García-Sancho C, Franco-Marina F, González-Cruz H. [Prevalence of severe periodontal disease and its association with respiratory disease in hospitalized adult patients in a tertiary care center]. Gac Med Mex. 2015;151(5): 608–613. 10. National Institute of Dental and Craniofacial Research. Data and statistics. 2012. Available at: http://www.nidcr. nih.gov/DataStatistics. Accessed February 28, 2015. 11. Medicare.Gov. Your Medicare coverage: dental services. Available at: https://www.medicare.gov/coverage/ dental-services.html. Accessed December 3, 2016. 12. Clothier B, Stringer M, Jeffcoat MK. Periodontal disease and pregnancy outcomes: exposure, risk and intervention. Best Pract Res Clin Obstet Gynaecol. 2007; 21(3):451–466.
Peer Reviewed
Public Health Policy
S63
AJPH POLICY
13. Xiong X, Buckens P, Goldenberg RL, Offenbacher S, Qian X. Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy? Am J Obstet Gynecol. 2011;205(2):111e1–111e6.
26. Jensen PM, Saunders RL, Thierer T, Friedman B. Factors associated with oral health–related quality of life in community-dwelling elderly persons with disabilities. J Am Geriatr Soc. 2008;56(4): 711–717.
38. Nasseh K, Vujicic M. Dental benefits coverage increased for working-age adults in 2014. 2016. Available at: http://www. ada.org/~/media/ADA/Science and Research/HPI/Files/HPIBrief_1016_2. pdf. Accessed December 3, 2016.
14. Offenbacher S, Beck JD. Commentary: changing paradigms in the oral disease–systemic disease relationship. J Periodontol. 2014;85(6):761–764.
27. Sischo L, Broder HL. Oral healthrelated quality of life: what, why, how, and future implications. J Dent Res. 2011; 90(11):1264–1270.
39. Eke PI, Dye BA, Wei L, et al. Update on prevalence of periodontitis in adults in the United States: NHANES 2009 to 2012. J Periodontol. 2015;86(5):611–622.
15. Cigna. Improved health and lower medical costs: why good dental care is important. 2013. Available at: https:// www.cigna.com/assets/docs/life-walllibrary/Whygooddentalcareisimportant_ whitepaper.pdf. Accessed March 20, 2015.
28. Leiendecker TM, Martin G, Moss DL. 2008 Department of Defense (DoD) recruit oral health survey. Mil Med. 2011; 176(8 suppl):1–44.
40. Vujicic M, Nasseh K. Accountable care organizations present key opportunities for the dental profession. 2013.
16. Allareddy V, Rampa S, Lee MK, Allareddy V, Nalliah RP. Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. J Am Dent Assoc. 2014;145(4):331–337. 17. Clementino MA, Pinto-Sarmento TC, Costa EM, Martins CC, GranvilleGarcia AF, Paiva SM. Association between oral conditions and functional limitations in childhood. J Oral Rehabil. 2015;42(6):420–429. 18. Pew Center on the States. The state of children’s dental health: making coverage matter. 2011. Available at: http://www. pewtrusts.org/~/media/legacy/uploadedfiles/ wwwpewtrustsorg/reports/state_policy/ childrensdental50statereport2011pdf.pdf? la=en. Accessed February 28, 2015. 19. Oral Health in America: A Report of the Surgeon General. US Department of Health and Human Services: Rockville, MD; 2000.
29. US Department of Health and Human Services. 20 million people have gained health insurance coverage because of the Affordable Care Act, new estimates show. 2016. Available at: https://www.hhs.gov/ about/news/2016/03/03/20-millionpeople-have-gained-health-insurancecoverage-because-affordable-care-actnew-estimates. Accessed January 29, 2017. 30. Nasseh K, Vujicic M, O’Dell A. Affordable Care Act expands dental benefits for children but does not address critical access to dental care issues. 2013. Available at: http://www.ada.org/~/media/ADA/ Science%20and%20Research/Files/ HPRCBrief_0413_3.pdf. Accessed December 3, 2016. 31. Vestal C. Adult dental coverage expanding slowly in Medicaid. 2015. Available at: http://www.pewtrusts.org/ en/research-and-analysis/blogs/stateline/ 2015/6/10/adult-dental-coverageexpanding-slowly-in-medicaid. Accessed December 3, 2016.
20. Hirotomi T, Yoshihara A, Ogawa H, Miyazaki H. Number of teeth and 5-year mortality in an elderly population. Community Dent Oral Epidemiol. 2015;43(3): 226–231.
32. Henry J Kaiser Family Foundation. Status of state action on the Medicaid expansion decision. Available at: http:// kff.org/health-reform/state-indicator/ state-activity-around-expandingmedicaid-under-the-affordable-care-act/ ?currentTimeframe=0. Accessed December 3, 2016.
21. Zabos GP, Northridge M, Ro M, Trinh C, Vaughn R, Moon J. Lack of oral health care for adults in Harlem: a hidden crisis. Am J Public Health. 2008;98(9 suppl): S102–S105.
33. McWilliams JM, Chernew ME, Dalton JB, Landon BE. Outpatient care patterns and organizational accountability in Medicare. JAMA Intern Med. 2014; 174(6):938–945.
22. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a national perspective. Ann Emerg Med. 2003;42(1):93–99.
34. Carlson RJ. Preemptive public policy for genomics. J Health Polit Policy Law. 2008;33(1):39–51.
23. Davis EE, Deinard AS, Ma¨ıga EW. Doctor, my tooth hurts: the costs of incomplete dental care in the emergency room. J Public Health Dent. 2010;70(3): 205–210. 24. Lee HH, Lewis C, Saltzman B, Starks H. Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008. Am J Public Health. 2012; 102(11):e77–e83. 25. Rayman S, Almas K. Halitosis among racially diverse populations: an update. Int J Dent Hyg. 2008;6(1):2–7.
S64
Public Health Policy
Available at: http://www.ada.org/ ~/media/ADA/Science and Research/ HPI/Files/HPIBrief_0413_2.ashx. Accessed February 28, 2015.
35. The Power of Prevention: Chronic Disease... The Public Health Challenge of the 21st Century. Centers for Disease Control and Prevention: Atlanta, GA; 2009. 36. Sun BC, Chi DL, Schwarz E, et al. Emergency department visits for nontraumatic dental problems: a mixedmethods study. Am J Public Health. 2015; 105(5):947–955. 37. American Academy of Pediatric Dentistry. Early Childhood Caries (ECC). Available at: http://www. mychildrensteeth.org/assets/2/7/ ECCstats.pdf. Accessed January 29, 2017.
Peer Reviewed
Mayberry
AJPH
Supplement 1, 2017, Vol 107, No. S1
