Editor’s note: For more on this topic, stay tuned for the December issue of Health Affairs, which will feature a cluster of articles on oral health.
Dental and medical care have almost always been delivered separately and disjointedly. That division of care could now change. Provisions in the Affordable Care Act (ACA) offer new opportunities to bring medical and dental care delivery closer to one another in two ways.
First, the ACA includes pediatric oral health benefits among its list of essential health benefits, giving insurance plans the opportunity to embed pediatric dental benefits within the medical plan. Second, the ACA strives to improve quality of care while containing costs via health care delivery reform in patient-centered medical homes and accountable care organizations (ACOs).
The ACA’s construct of health care places the patient at the center of care delivery of all kinds, including behavioral, mental, dental, and vision care. about this move toward patient-centered care, but financial and practical often stymie a more coordinated effort to join dental and medical care.
Dental care in hospital emergency departments (EDs) provides an excellent opening to improve, integrate, and coordinate care via ACOs or other kinds of clinically integrated networks. The majority of ED visits for dental care involve only, with prescriptions for antibiotics and analgesics. While timely for the patient, such care bypasses definitive treatment, fails to address the source of infection, and increases costs associated with that tooth’s eventual treatment.
Most ED dental visits are financed by or self-paying patients. In 2012 these visits accounted for nearly 2 percent of all ED visits, consumed $1.6 billion—roughly 3 percent of all ED expenditures—and averaged $749 per visit. It is estimated that of ED dental visits could be avoided if preventive care were more routine, translating to as much as to a single state Medicaid program. Realizing such savings helps achieve the triple aim goals of the ACA.
ACOs as Mechanisms for Coordinating Care
An ACO or clinically integrated network assumes a degree of financial risk to care for its patient population and must deliver high-quality care that reduces associated costs to share in cost savings. is essential to the success of ACOs, with some suggesting coordination as “the most promising path towards financial sustainability (emphasis added).”
In the ACO model, care coordination often occurs at the individual level; success, however, requires a structure of coordination even before the patient enters the system. Indeed, more health systems are recognizing the importance of working with community partners to manage chronic diseases and keep patients healthy outside an expensive hospital setting. Oral diseases should be no exception. Systems that improve coordination of dental and medical care will have the best chance of improving quality for individual patients, improving population health, and containing costs.
Data from a suggest 14 percent of ACOs now include dental care among the services they provide. ACOs responsible for dental services are more likely to have Medicaid contracts (25 percent) than commercial contracts (around 10 percent), as well as to include federally qualified health centers, vision and hearing services, and mental health and substance abuse services. Around one-third of these ACOs have co-located dental and medical care, another third offer dental care in a separate or nearby clinic, and the final third contract out their dental care to multiple dental practices.
No matter the coordination mechanism or ACO characteristics, reimbursement is an important piece of the puzzle. In many managed care contracts, medical care is paid on a capitated, or per-member-per-month basis, while dental care is often carved out and paid via a traditional fee-for-service (FFS) system.