Experts from the worlds of policy, business, academia, and health care gathered last spring for a Leadership Forum hosted by the Harvard School of Dental Medicine (HSDM) Initiative to Integrate Oral Health and Medicine. The forum explored the tremendous growth of Medicare Advantage plans and the implications for oral health and access to dental care for Americans over age 65.
Stakeholder Engagement
Dr. David Blumenthal, professor of the Practice of Public Health and Health Policy at Harvard T.H. Chan School of Public Health, delivered an engaging keynote on the successes and current challenges of the Traditional Medicare (TM) and Medicare Advantage (MA) programs and what they mean for oral health and dental care.
“Participation in Medicare Advantage plans continues to surpass that of participation in Traditional Medicare,” Blumenthal said. “They are attractive because they cover hospital, outpatient, and pharmacy expenses, with limited or no out-of-pocket contributions from beneficiaries.”
The plans also offer supplemental benefits such as dental, vision, and hearing, that are not typically included in TM. The catch is that the plans generally require both: that care be provided “in network” and that prior authorization be obtained. The experts in attendance noted that it can be difficult to get payers to support integrated care models, despite the popularity with patients.
Drs. Lisa Simon of Harvard Medical School and Darien Weatherspoon of the University of Maryland shared research on the lack of utilization of TM and MA dental benefits. Potential reasons identified include beneficiaries not understanding their benefits and/or having concerns about incurring out-of-pocket expenses, a lack of providers willing to accept MA reimbursements, transportation issues, or other health concerns preventing beneficiaries from seeking care at a dental office.
“Untapped funds for supplemental benefits could help explain why MA plans realize a significant surplus each year,” said Blumenthal, who hypothesized that the annual plan renewals and patient “churn” deter plans from reinvesting any surplus.
Increasing Access and Opportunity
Dr. Natalia Chalmers, the chief dental officer for the Centers for Medicare & Medicaid (CMS), spoke about the challenges and opportunities in delivering dental care to the millions covered through CMS programs.
“We have been actively engaging with stakeholders (e.g., states, plans, providers, advocacy groups) to identify opportunities to increase access to care through existing authorities and plan flexibilities,” said Chalmers. “We’ve had success clarifying Medicare coverage for medically necessary dental care for services related to transplant surgeries, head and neck oncology, and other interventions for complex care.”
Panelists agreed there has been progress clarifying access to medically necessary dental care. Like Dr. Chalmers, they believe there are many opportunities to integrate care and benefits, to improve equity, and to enhance health outcomes. Additionally, state-level experiments in Medicaid accountable care organizations were identified as holding great promise as blueprints for how to integrate care in a financially viable way for other patient populations, such as those with intellectual and developmental disabilities.
Real-World Innovations
The forum featured discussions on real-world innovations in integrated benefits, care delivery, and health education that strive to provide equitable holistic care to older adults and others across their lifespan. A discussion with Dr. Russell Philips of HMS, Mr. Steve Thorne, CEO of Pacific Dental Services (PDS) Health, and Dr. David Kim of Memorial Care California, highlighted a joint venture that aims to provide comprehensive dental care to Memorial Care patients via PDS Health integrated medical and dental practices.
“There is significant opportunity to improve health outcomes and potential to lower downstream expenditures by increased access to dental care for this patient population,” said Thorne and Kim.
This theme was echoed by other speakers who discussed efforts to integrate dental care into chronic disease management protocols, the integration of behavioral health screenings into dental practices, and embedding dental hygienists into primary care practices.
Interprofessional Education
Presentations on medical-dental integration included examples of interprofessional education designed to prepare health professionals to work together to provide holistic, integrated care. One example is the 100 Million Mouths project led by HSDM.
“The 100 Million Mouths project aims to create oral health champions in each of the 50 states to help all health professions training programs incorporate oral health competencies into their curricula and to train primary care providers how to apply fluoride varnish,” said HSDM faculty member Dr. Shenam Ticku.
Other examples included the National Dental Association’s oral health training program for clinical nurses and HSDM’s efforts to teach oral health competencies to medical trainees.
“There’s enthusiasm from our trainees when learning about oral-systemic connections and how they can play a role in promoting the oral health of their patients,” said UMass Chan Medical School professor and HSDM lead researcher, Dr. Hugh Silk. “They often wonder why oral health historically has been omitted from their didactic curricula and clinical training activities when it is so important.”
Throughout the forum, the audience was engaged and asked probing questions. Many ideas were generated for partnerships across academia, health plans, and provider groups to launch demonstration projects aimed at advancing medical-dental integration.
“It was a robust couple of days,” said Bob Lewando, co-chair of the Initiative and executive director of Blue Cross Blue Shield of Massachusetts Dental. “Participants learned a lot about opportunities and challenges in MA for oral health and some real-world success to help advance integrated care.”
