Examining Dentistry’s Future
3 delivery models poised to impact dental care
Ellen Meyer, MBA
As a result of philosophical and structural changes in health care, three distinct models of oral health care delivery are gaining traction. These models are emerging from the need to address economic issues, an increased understanding of the relationship between oral and general health, and the advent of government-mandated health coverage, which includes coverage for pediatric oral health in state Medicaid programs and state exchanges.
The models include dental support organizations (DSOs), which offer an alternative to solo practice and handling the business of dentistry; the use of licensed dental therapists or other midlevel providers to help shoulder the enormous burden of delivering care—especially to children, the elderly, and those in remote areas; and medical-dental collaborative practice, which integrates dental and medical care to improve overall outcomes and potentially significantly lower cost.
A number of professionals representing different points of view recently weighed in with Inside Dentistry on the “how” and “why” of the emergence of these models, and how they can achieve the ultimate goal of expanding access to care.
Dental Support Organizations
One response to changing realities of the health care landscape has been the rise of dental support organizations (DSOs). Although some regard DSOs as a troublesome disruptor of a longstanding private practice model—that of the beloved solo practitioner treating families in a community—there is little dispute that they are here to stay.
Quinn Dufurrena, DDS, JD, is executive director of the Association of Dental Support Organizations (ADSO), whose membership includes DSOs of all sizes as well as vendors to the dental industry. He sees “a vastly altered health care environment that is dictating the emergence of DSOs.”
Heartland Dental is the largest of the DSOs, with more than 675 supported dental offices located within 31 states, including more than 1,000 dentists and 7,000 team members. As director of recruitment at Heartland Dental, Nancy Pals points to the existence of a “multitude of challenges facing modern dentists in the ever-changing dental industry,” which makes DSOs an option that resonates with many dentists at various stages of their careers. “DSO support helps dentists be dentists. It also offers an attractive alternative to private practice for many, including recent dental grads with high debt loads and fewer associate opportunities, and, at the other end of the career spectrum, dentists close to retirement who have limited transition options.”
Brad Guyton, DDS, MBA, MPH, who is dean of dentist development, Pacific Dental Services, another of the largest DSOs, brings the perspective of a clinician, educator, and business executive to the discussion. Describing that environment, he observes what he calls “a perfect storm in the dental industry,” including “a groundbreaking shift in the complexity and reimbursement mechanisms of dental insurance; rising costs of dental technology, while patients demand more of these features; rising debt of students; increased supply of dentists; demographic shifts in graduating dentists; and a slowing demand for adult dental care in the US, according to NADP statistics.”
According to Guyton, “Dentists supported by DSOs often benefit from more efficient and effective systems, economies of scale, negotiating power with third-party payers and suppliers, and access to unique platforms for professional collaboration and mentorship that allow for not only competitive advantage in the marketplace, but faster clinician ramp-up, development, and greater access to care for the dentally underserved.”
Certain advantages may also enable DSOs to provide greater access to health care among diverse populations—including those on Medicaid—than solo practitioners. Mike Plunkett, DDS, MPH, is associate director for strategy and business development at Permanente Dental Associates (PDA), which partners with Kaiser Foundation Health Plan to form the Kaiser Permanente (KP) Dental Program. He maintains that the larger and more diverse organizational structure of DSOs enables them to consider providing service to different types of populations. “Larger organizations have more access to capital, so they can develop capacity quickly and experiment with their dollars—in other words, divest and invest. They can actually create bifurcated systems with different scheduling methods and services for the different patient populations, whereas solo practitioners are challenged due to the smaller scale of their operations and associated costs.”
However, Plunkett also mentions a disadvantage of the DSO model: higher provider turnover rates—especially where dentists are employees. “When you have higher turnover of providers, you don’t get that long-term investment in a relationship with the patients, which fosters practice loyalty, consistency of treatment, and stability in the workforce.”
Help managing the business aspects of practice, the need for increased buying power in the current economy, and the potential for increased access to care are attractive advantages of the DSO model. Practitioners who still balk at the idea may find collaboration in other forms more comfortable (see sidebar “Independence Meets Buying Power”).
Plunkett states that his organization’s primary focus is supporting a medical and dental collaborative model as a prelude to the full integration of oral and medical health care delivery. This process, he adds, will be optimized by migration to a single integrated electronic health record (EHR) system (see sidebar “Managing Information”).
“Dentists have already proven to be essential partners in patient-centric collaborative models that address obstructive sleep apnea, oral/head and neck cancer, cleft palate, oral maxillofacial surgery, and other conditions,” he says. “The profession can build off these established examples of collaborative practice to create scalable models that add tremendous value by serving as extenders of primary care teams.” He says that because patients see them more frequently than other providers, “dentists are well positioned to be a critical touch point in the health care continuum by assisting in early detection of many of the chronic diseases that contribute significantly to health care costs.” It is feasible, he notes, to envision the incorporation of care professionals such as physician assistants (PAs), nurses, or RDHs with advanced training into dental practice to expand the scope of services to include enhanced screening and referral for chronic disease.
An integrated medical-dental system offering expedited access to evidence-based oral health care would come into play in a situation that is all too familiar to Plunkett. “Often the biggest barrier to timely major cardiovascular and orthopedic surgery is acquiring dental clearance due to the presence of oral infection that increases the risk of post-surgical infection. Dental clearance is also often a challenge for head and neck cancer teams preparing patients for radiation therapy,” he explains.
Yet the kind of fully operational integrated oral and medical health care Plunkett and his colleagues advocate exists to date on a large scale only in the Kaiser Permanente NW care model in Oregon and Washington, where 90% of dental members served are covered both dentally and medically by the same system. The NW is the only one of seven KP regions with a combined medical and dental delivery capability. Regions outside the NW utilize traditional dental partners such as Delta Dental to provide insurance and care.
Plunkett notes the existence of “pockets of innovation” in which inroads have been made in the direction of integration. Among them is the Virginia Oral Health Coalition (VaOHC). Sarah Holland is the executive director for this statewide advocacy organization, whose mission is to integrate oral health into all aspects of health. This work has revolved primarily around policy change related to Medicaid benefits. But in addition to the coverage provided for children through the Affordable Care Act (ACA), her organization was recently successful in “advocating for dental benefits for women enrolled in Medicaid.” She says a number of community health centers in Virginia are in the midst of creating obstetrics programs that include oral health, making sure that women who use it are getting a lot of education for themselves and their children, starting at age 1.
Among the more controversial approaches to improving access to care is an expansion of the dental workforce at a time when many dentists are not as busy as they would like to be.
Guyton acknowledges that the topic of midlevel providers is something of a “third rail” with many clinicians, but he strongly believes they will be part of future business models of dentistry much as they have been in medicine. “Nurse practitioners (NPs) and PAs have positively impacted patient health and experiences on the general practice side of medicine, and in fact, I myself see and trust a PA for my routine medical visits.”