A longstanding advocate for integrating oral health and overall health, Robert Lewando, DDS, MBA, is Executive Director, Dental, for Blue Cross Blue Shield of Massachusetts, a position he assumed in 2012 after serving as Clinical Director for 8 years. Dr. Lewando is a graduate of the Wallace E. Carroll Graduate School of Management at Boston College and took his dental degree from Columbia University School of Dental and Oral Surgery.
Welcome Dr. Lewando! What was the draw for you to become a part of Harvard School of Dental Medicine’s Initiative?
I always thought that we [health professionals] made an arbitrary distinction between what is considered treatment to improve oral health and what is treatment to improve overall health. C. Everett Koop, the 13th surgeon general of the United States said, “a person cannot be healthy without good oral health.” I believe this as well and the Harvard School of Dental Medicine Initiative is at the forefront of making this widely held belief a reality.
Will you share your vision for the HSDM Initiative?
My vision for the HSDM Initiative is to be the preeminent thought leading organization for helping to integrate oral health into primary care, preventive care, and chronic disease management programs. We are looking to achieve greater health access to care and improve health outcomes for all people. We do this by creating a collaboration of like-minded stakeholders with medical, dental, public health, education, and industry backgrounds to make these changes a reality. The Initiative is the resource to show the clinical value of integration, lobby stakeholders on the need to change, and describe implementation pathways that can be used to make impactful changes happen. Our success will be measured by the seamless integration of oral health in all related health activities necessary to keep people healthy.
Will you tell us some of the ways that primary care and oral healthcare team members can work together to improve the health outcomes of their patients?
I am a periodontist by training. Many years ago, I saw patients in my practice that were diabetic and needed periodontal treatment. It was not uncommon for the patient to come back to the office after the completion of treatment and tell us that they were told by their physician that their diabetes was under better control. At the time, I did not understand that improving the patient’s oral health, by decreasing oral inflammation, would also have a systemic effect on their diabetes.
I am in a practice that uses a combined medical and dental electronic record. I routinely will consult with my patient’s primary care practitioner about the patient’s chronic diseases and what I might be able to do— from a dental standpoint— to improve their oral health and contribute to their overall health. Primary care physicians in my practice also understand this relationship, and refer patients to seek dental care, supporting the fact that oral health is important in the management of the patient’s medical condition.
Why would it be helpful for primary care clinicians to routinely examine the mouth?
Many health care practitioners are involved in the care of the patients. Just as it is the responsibility of the dentist to diagnosis oral diseases as well as identify abnormalities that will need follow-up by the physician, the physician holds these same responsibilities. It has been well documented that what occurs in the mouth has an effect on the rest of the body, therefore it is incumbent on the physician to look in the mouth to see if there are problems that need dental follow-up and improve a dental risk factor in the overall management of their patients. In fact, the Department of Public Health in Massachusetts put an oral health examination of the patient in their Guidelines as to what should be done by physicians when they are evaluating a diabetic patient.
What are some of the barriers that might exist preventing medical-oral health integration?
Medical and dental coding, insurance, and practitioner training have progressed along parallel paths since their inception, but lack coordinated communication. Current coding, insurance, and reimbursement mechanisms make this integration difficult. Instead of looking at a specific treatment as medical or dental, we should look to see if the treatment is provided to achieve a medical or dental outcome. If treatment is undertaken to have a positive effect on the control of the medical condition, such as periodontal treatment to improve the control of diabetes, it is reasonable to think that such treatment would be covered under the medical benefit. This is exactly what Medicare is doing in incorporating dental coverage for conditions that will help improve medical outcomes.
How can medical professionals overcome these barriers?
Attitudes are changing over time. Alternative quality contracts are developing so that physicians are being compensated as to how well they are taking care of the health needs of their patients. As more evidence and data comes out about how oral health plays a role in the overall management of the patient, physicians will realize the importance of having dentists as a part of the patient’s care team to maximize the member’s health and reimbursement for doing so.