Publications by Type: Report

Executive Summary

Noncommunicable chronic diseases (NCDs) account for almost 90% of total deaths in the United States.1 The four most common NCDs—cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases—share common risk factors, including cigarette use, alcohol use, and dietary behaviors associated with obesity and elevated blood sugar.1 The most common oral diseases—dental caries, periodontal disease, and oral cancer—also share these same risk factors.

A coordinated approach to primary prevention, the “common risk factor approach,” argues that coordinated primary prevention of oral and systemic diseases will reduce programmatic costs, and increase efficiency and effectiveness..2 However, use and evaluation of this coordinated approach in primary prevention activities in the United States has not been well documented.

This report describes the results of an environmental scan to identify, categorize, and describe examples of medical-dental integration in US public health settings. Findings are intended to inform public health officials and other stakeholders about existing programs and policies that encourage coordination and integration.

Research brief written by the ADA Health Policy Institute in partnership with The Dartmouth Institute for Health Policy & Clinical Practice. March 2016.

Key Messages  

• Most accountable care organizations (ACOs) are not responsible for dental care as part of their ACO contract. Nine percent of the largest commercial contracts and 25 percent of Medicaid contracts hold providers responsible for the cost and quality of dental services.
• The top reason ACOs report for excluding dental care is a lack of integrated health information technology. The perceived potential for cost savings associated with dental care is the top motivation among ACOs that include or plan to include dental care.  
• Despite research suggesting that integration of dental care may benefit patients, financing and delivery of dental care remains disconnected from other health services, even among ACOs working to improve overall population health. Integration of dental care may present an opportunity for improved accountability for total health, yet to date, there is little incentive for ACOs to facilitate access to these services. 

Research Brief written by the ADA Health Policy Institute (HPI), a thought leader and trusted source for policy knowledge on critical issues affecting the U.S. dental care system.

Key Messages

• In a tertiary health care setting, physicians reported they were dissatisfied with the referral system to dentists, the coverage of dental care services for patients, and their ability to distinguish a worrisome oral lesion from a variant of normal.
• More than half of worrisome lesions were referred to physician specialists instead of dentists specifically due to the lack of a referral system.
• Efforts to improve the referral system to dentists, facilitate the creation of an electronic referral system, and promote dental education for physicians could increase both physician and dentist satisfaction and the quality and efficiency of care for patients.

This white paper was commissioned by the National Interprofessional Initiative on Oral Health with support from the DentaQuest Foundation, the REACH Healthcare Foundation, and the Washington Dental Service Foundation.

Forward

Strengthening the primary care delivery system, investing in prevention, and reducing unnecessary costs are national healthcare priorities. As the leaders of organizations committed to advancing oral health, we see a clear opportunity to improve health, reduce waste, and maximize the value of our limited healthcare workforce by incorporating oral health in routine medical care.

We commissioned an initiative to develop, test, and disseminate an actionable pathway for delivering preventive oral health care in the primary care setting, and improving the structure of referrals from primary care to dentistry. We assembled a Technical Expert Panel to guide this effort, which included primary care and dental care providers, medical and dental associations, payers and policymakers, a patient and family partnership expert, and oral health and public health educators and advocates.

Based on input from this panel, and a careful review of previous efforts to integrate once fragmented services into primary care, the authors developed an organizing framework, which we present in this white paper.

The Oral Health Delivery Framework has been endorsed by a broad array of organizations, and is consistent with how primary care teams manage preventive, acute, and chronic care needs for a wide range of clinical conditions across the lifespan. As such, we believe that implementation of the Framework is an achievable goal.

It has been 15 years since the U.S. Surgeon General identified oral disease as a priority health concern and documented pervasive and systemic barriers to dental care. Despite calls for all healthcare professionals to pay attention to oral disease, too little progress has been made in reconfiguring the healthcare delivery system to better meet our nation’s oral health needs. Only by partnering together can we reduce the burden of oral disease. We hope that the information presented in this white paper will inspire primary care teams and dental health professionals—and the stakeholders that support them—to end the artificial separation of oral and systemic health.

The U.S. Department of Health and Human Services (HHS) is committed to advancing the oral health and general well-being of all populations across the lifespan. The HHS Oral Health Strategic Framework 2014–2017 outlines a strategic alignment of HHS operating and staff divisions’resources, programs, and leadership commitments to improve oral health care and delivery.

The Framework is written for oral health, behavioral health, and primary care health professionals and program administrators within and outside of the federal government and other external stakeholder groups interested in oral health. It serves as an essential resource to (1) optimize the implementation of activities planned and those underway, (2) strengthen existing cross-agency collaboration, and (3) identify new avenues for private-public partnerships by creating maximum synergy with other current federal and non-federal oral health initiatives.

Lack of access to oral health care contributes to profound and enduring oral health disparities in the United States.  Millions of Americans lack access to basic oral health care.  In 2008, 4.6 million children – one out of every 16 children in the United States did not receive needed dental care because their families could not afford it.  Children are only one of the many vulnerable and underserved populations that face persistent, systemic barriers to accessing oral health care.   

The United States health care system is able to provide acute care but continues to struggle to address the need for ongoing care, especially for vulnerable populations such as the elderly, disabled, mentally ill, and special needs populations.  Safety net organizations that provide health services to uninsured, low-income, and vulnerable persons continue to look for ways to coordinate services among providers to improve access to quality care.  

The 2011 Institute of Medicine (IOM) reports, Advancing Oral Health in America and Improving Access for Oral Health for the Vulnerable and Underserved, recommended that the Health Resources and Services Administration (HRSA) address the need for improved access to oral health care through the development of oral health core competencies for health care professionals.  In response, HRSA developed the Integration of Oral Health and Primary Care Practice (IOHPCP) initiative with three inter-related components.  The first component was the creation of a HRSA prepared draft set of oral health core clinical competencies appropriate for primary care clinicians.  The second component was the presentation of a systems approach to delineate the interdependent elements that would influence the implementation and adoption of the core competencies into primary care practice.  Finally, the third was the characterization and outline of the basis for implementation strategies and translation into primary care practice in safety net settings.