Bridging Medical and Oral Health Care: Case Studies
Financing structures, delivery systems, workforce, and professional education for oral health care and medical care have traditionally been very separate, but there are promising national, state and local efforts to incorporate oral health into primary care. Examples include programs to train medical providers to assess oral health conditions; implementing an integrated medical and dental electronic record system; and incorporating oral health into delivery system reforms. In this section of the toolkit, you will find case studies of initiatives in progress and links to online resources that describe technological, financial, and educational approaches to bridging oral health and the overall health care system.
Case Study: Marshfield Clinic and Family Health Center
A community health center system in Wisconsin is seeking to demonstrate how better connections between dental and medical providers can improve health care and outcomes for low-income individuals with diabetes. It may provide a model for states seeking new strategies to promote integrated care for high-cost beneficiaries.
Family Health Center of Marshfield, Inc. (FHC), a large Federally Qualified Health Center system in Wisconsin, and the Marshfield Clinic, one of the largest private group medical practices in the state, are working together on initiatives to better integrate medical and dental care for people with diabetes. Taking advantage of FHC’s network of nine large dental clinics across the northern and central parts of the state, these clinics represent a new model of service delivery for rural areas. FHC’s goal is to eliminate disparities in access to oral health care between uninsured or Medicaid-enrolled individuals and the privately insured.
Approximately three quarters of FHC’s dental patients receive medical care from the Marshfield Clinic Health System. This represents an opportunity for collaboration, and FHC’s capacity to deliver dental care allows FHC and Marshfield to engage medical providers in identifying and managing oral health conditions, because medical providers can be confident that patients they refer can access dental care.
FHC began looking at linkages between oral health and overall health out of an interest in providing whole-person care, and in light of evidence linking untreated gum disease to worsened diabetic control. FHC has pursued a number of strategies to bridge oral health and primary care, including developing fully integrated medical and dental electronic health records and clinical decision support tools to assist both dentists and physicians to co-manage patients with diabetes. Grant funding from the DentaQuest Foundation supported a pilot program, conducted in coordination with a managed care plan, to test patient education and incentive strategies to encourage individuals with diabetes to establish regular oral health care.
Medical providers at pilot sites are able to conduct routine visual oral examinations for their diabetic patients along with annual foot and eye exams to treat common consequences of diabetes, and track whether their diabetic patients are receiving treatment for gum disease. The clinical decision support tools prompt medical providers to talk to patients about their use of dental care, and refer if necessary. FHC dentists at pilot sites now monitor diabetics’ blood sugar in the dental office. To complement the integrated systems, Marshfield Clinic Research Foundation, Marshfield Clinic Division of Education and FHC have also focused on training their clinicians to work in this new paradigm and developed the Institute for Oral-Systemic Health to research, update, and advance these integrative efforts.
Although the pilot programs are still being implemented and evaluated, integration has already led to noticeable improvements for FHC patients, according to Greg Nycz, FHC’s executive director. “You don’t have to talk to many of our dentists and hygienists to convince them of the connection between periodontal disease and major health complications. In patient after patient, we see that if we address their periodontal disease and get their health back on track, we can provide a new lease on life.”
State policies underpin FHC’s efforts to coordinate medical and dental care.
Medicaid adult dental coverage. Greg Nycz notes that Wisconsin Medicaid’s consistent coverage of adult dental services is critical to FHC’s ability to expand its capacity to deliver oral health care and improve access to integrated oral health services for its patients. Medicaid-enrolled patients comprise about 65 percent of the clinics’ caseload; if adult dental services were not a Medicaid benefit, FHC would not be able to financially sustain these services.
State appropriations. The state has also used direct annual appropriations to support safety net dental capacity in rural areas of the state. In November 2002, FHC received $232,000 in state funding to support a 17-chair dental clinic in Ladysmith, Wisconsin, a town in rural Rusk County (county population: 14,395). A second 29-chair FHC clinic in Chippewa Falls (in Chippewa County, population 63,132) opened in September 2005, and was supported by an appropriation of $400,000. While annual state appropriations for the clinics have fallen over time to a current level of approximately $526,000, these funds remain important to sustaining the program.
- In FY2014, FHC dental centers treated 49,389 unique patients. Over the last decade, over 100,000 unique patients from all 72 counties in Wisconsin have had access to dental services through these dental centers. The rural clinics’ reach extends to distant urban areas, often drawing people more than three hours from major metropolitan areas to far more remote parts of the state in order to get dental services.
- FHC reports that it has been successful in reducing visits to hospital emergency rooms for treatable dental conditions. In the year following the opening of the Chippewa Falls clinic, the number of non-traumatic dental-related emergency room visits fell from 139 in 2009 to 115 in 2010, and continued to fall to just eight in 2012.
- Researchers at the Marshfield Clinic Research Foundation (MCRF), through the Institute for Oral and Systemic Health, have developed one of the first fully integrated medical-dental Electronic Health Records in the nation.
- The pilot project training dental providers to conduct blood glucose tests at chairside for at-risk diabetic patients will likely be expanded to all 9 FHC dental centers in the next 8-12 months. Likewise, Marshfield Clinic is planning to expand training for medical providers on how to conduct routine visual oral examinations for diabetic patients to 4-5 other Marshfield Clinic medical centers in the next 12 months.
- Marshfield Clinic Institute for Oral and Systemic Health
- 2013 testimony by Greg Nycz to the Senate Subcommittee on Primary Health and Aging on “Dental Crisis in America: The Need to Address Cost”
- 2014 NASHP Conference Presentation by Greg Nycz on WDSF Toolkit – Content Summary .docx “The Importance of Medical/Dental Integration in the Care of Diabetic Patients”
 Federally Qualified Health Center (FQHC) is a designation granted by the federal Health Resources and Services Administration to Community Health Centers that must be located in a medically underserved area or serve a medically underserved population.
Case Study: Oral Health and Oregon’s Coordinated Care Organizations
Oregon’s regional Coordinated Care Organizations (CCOs) include dental care alongside physical and behavioral health in delivering whole-person care. Although early in the implementation process, Oregon’s delivery system reform may provide a model for states interested in more closely coordinating medical and dental care services to increase quality of care and drive down costs.
State Action: Legislative Framework
In 2011, Oregon enacted House Bill 3650 (HB 3650) – creating a new payment and delivery structure known as a “Coordinated Care Organization” (CCO). Each of the state’s 16 CCOs is a regional accountable care entity that delivers physical and behavioral health services to Medicaid enrollees under a single budget. However, unlike most other states pursuing accountable care arrangements, Oregon’s law explicitly recognized dental services alongside physical and behavioral health in its vision for whole-person care. The law requires that “On or before July 1, 2014, each coordinated care organization must have a formal contractual relationship with any dental care organization that services members of the coordinated care organization in the area where they reside.” Through this legislation, Oregon created a regulatory framework that required a relationship between historically distinct and separate providers (primary care, mental health, and dental) that established the foundation for an integrated delivery system.
As CCOs were established, and it came time to satisfy the various requirements of HB 3650, stakeholders began to identify operational opportunities and challenges with integrating dental care. One of the most challenging and time-intensive operational obstacles was the requirement that each CCO contract with every dental care organization (DCO) in the region. In the Portland Metro area this meant that CCOs had to contract with as many as 8 DCOs. Coordinating care is a new process for dental providers and payors, who have been traditionally separate from medical delivery and payment systems. The requirement of HB 3650 provided motivation for medical and dental actors to move beyond the philosophical question of “why should we coordinate” to the operational questions of how to make coordination work. Over time, CCOs and DCOs have established working relationships to coordinate implementation, meet the requirements, and meet both organizations’ needs while providing quality care.
State Action: Incentive Payments
Oregon encourages collaboration between CCOs and DCOs by adding financial incentives to a number of metrics, including one dental measure. CCOs receive braided funding to provide medical, behavioral, and dental services that assumes a set per capita trend cap. A percentage of the funding is withheld (currently 3%) that is placed in an incentive pool. The CCOs performance on certain metrics determines what they can earn back. The impact on the CCO/DCO relationship is that CCOs have to work with DCOs to identify improvement strategies, foster communication, and referral relationships between medical and dental providers. In addition to improving performance on the dental measure, CCO performance on other measures can also benefit indirectly from enhanced dental care – for example, lower emergency room utilization through improved access to preventive dental services. In other words, dental is now part of the overall picture.
To develop dental-specific metrics, the state formed an 11-person Dental Quality Measures Workgroup, including representatives from DCOs, CCOs, and experts in oral health, to recommend basic oral health metrics. Children’s utilization of dental sealants (clear plastic coatings that prevent decay in molars) was adopted as a metric because sealants are a measureable, basic and evidence-based dental prevention strategy. In 2015, the benchmark for dental sealants is 20% utilization across two age ranges (6-9 and 10-14). The state Medicaid agency analyzes data reported by each CCO, determines if the benchmark is met, and determines the amount of the associated incentive payment. Dr. Jeanene Smith, Chief Medical Officer at the Oregon Health Authority, noted that the added financial incentive is contributing to a “renewed interest” in dental integration efforts to improve overall health outcome, reduce emergency department use, and satisfy other related metrics.
Next Steps: Observing Pilot Programs
In order to reduce costs, qualify for incentive payments, and provide quality services to their service areas, CCOs are developing innovative solutions to drive down cost of care. Oregon’s Dental Director, Dr. Bruce Austin, said that several CCO pilot projects are currently underway that relate to dental care and seek to reduce the costs associated with health consequences of untreated dental issues. These include pilots related to emergency room diversion through early intervention and dental care; integrating dental hygienists into primary care settings; providing enhanced dental services to people with diabetes; and increasing the development and use of teledentistry. Dr. Austin indicated that the lessons learned from these pilots will drive the state’s thinking about oral health’s role in the next stage of reform.
While it is still early to draw conclusions about lessons from Oregon’s experience, clear themes have emerged from the experience:
- There is clear recognition of oral health as a component of whole-person care;
- Financial incentives provide motivation for stakeholders to bridge historically separate systems; and
- Fostering pilots that test the potential for realized savings from capitalizing on the links between oral health and overall health is a valuable state tool.
As CCOs and DCOs continue to pursue medical and dental integration, it will be interesting to watch as the state begins to draw conclusions about best practices for, and the value of, integrated dental and medical care.
- CCO Implementation Proposal
- HB 3650 (Text)
- SB 1580 (Text)
- HealthShare Oregon – About CCOs
- Dental Sealant Metric
 The workgroup’s recommendations included two measures of dental utilization for children that were considered for use in CCO incentive payments. Several others, including dental-specific measures from a patient satisfaction survey, are being monitored, and the measures group may reconvene as national progress is made on developing oral health outcome measures. See Eli Schwartz. PowerPoint presentation. “Dental Quality Metrics as Part of Oregon’s Health Transformation.” Presented at National Oral Health Conference, Ft. Worth, TX, April 29, 2014. Retrieved November 6, 2014. http://www.nationaloralhealthconference.com/docs/presentations/2014/04-29/Eli%20Schwarz.pdf.
 The Oregon Health Authority includes most of the state’s health care programs, including public health, Oregon Health Plan, Healthy Kids, employee benefits, and public-private partnerships.