The emergence of midlevel providers, says Plunkett, has been historically driven almost completely by the interest in expanding access to care. “Companies may adopt the model and incorporate the providers into their respective practices if they see the opportunity to deliver care at a lower expense. If large organizations or even small practices can lower costs, they can consider expanding into population segments like Medicaid, which have traditionally had very low reimbursements.” While Plunkett observes a “mission-driven thrust” where licensed dental therapists are used now, he says, “Financial evaluation must show a reduction in cost before provider organizations will adopt the model on a larger scale in the interest of expanding access to populations that have traditionally been underserved due to limited finances.”
In Guyton’s opinion, expanded and advanced practice of dental hygienists and other “midlevel” clinicians may allow for enhanced access for dental patients, but for this model to succeed, it must offer the following: financial benefit to both dentists and patients; improved quality of care; and an appropriate level of dentist supervision and formalized training. Most of all, he says, “They should not circumvent dentists or place at risk the dentist–patient relationship; instead, they should work in conjunction with dentists to expand outreach and access.” However, he predicts, “With greater integration of oral and general health care, this new type of provider—which could be a master-level trained advanced hygienist or dental therapist, or possibly a PA or NP with dental training—may someday serve as a conduit or liaison between physician care and dentist care.”
These qualifications and concerns notwithstanding, David S. Gesko, DDS, dental director and senior vice president of HealthPartners, who has direct experience with this model, is proud that his state of Minnesota was the first to license and use dental therapists. He has no doubt they already offer economic advantages, and predicts they will someday soon be as indispensible to dentistry as PAs and NPs are now to medicine—although there was originally significant pushback from doctors, much like dentists who fear their own displacement.
“I’m a big fan of midlevel providers—dental therapists—they’re a wonderful aid to our dental team. They have done exactly what they were intended to do—become a provider in the middle, allowing dentists to focus only on things dentists can do,” Gesko explains.
As for questions about the quality of care delivered, Gesko points out that dental therapists in Minnesota are trained alongside dental students, so insufficient training is not a concern. He says, “I can’t practice without them. The three we have in our HealthPartners practice are a great addition to our team.”
Similar to Kaiser Permanente, HealthPartners includes a medical group and comprehensive medical plan and a dental group and dental plan. Gesko recently presented data supporting the economic benefits of phasing in these lower-cost providers. “The initial data that I’ve presented recently was a very high-level analysis that says that dental therapists save 25%.” This, he says, confirmed his belief that it was a viable model businesswise. “When you can get the same work performed by someone who earns significantly less, it’s kind of a no-brainer.”
HealthPartners, says Gesko, is committed to serving Medicaid populations as well as commercial. “We’re probably 75% commercial, and 25% Medicaid, but everything we do at HealthPartners—medically and dentally—is founded on the triple aim of delivering great health outcomes and great patient experiences at affordable rates.” The dental therapy model, he says, fits perfectly into that objective.
Plunkett believes all three models have some opportunity to achieve the overall objective of efficiently and cost-effectively serving the health care needs of all segments of the population, including the underserved. “By virtue of their size and access to resources, the large corporate or group practices are well positioned to experiment with nontraditional workforce and care models to deliver services in different ways to meet the unique needs of different patient populations.” It must be noted, however, that the overwhelming majority of care is still provided and will continue to be provided in small dental practices. “Consequently, for any model to provide meaningful large-scale value, it must have some level of application in that model,” Plunkett says.
Guyton expects all three dental care models presented to continue to evolve, with DSOs continuing to grow fastest. He anticipates slower growth in the medical/dental collaborative model. “Although it arguably has the greatest potential for positive impact on the systemic health of patients, its success requires fundamental changes in how we approach and pay for care,” he says. He predicts that midlevel provider models will generally progress very slowly over the next decade, but “with pockets of success in the treatment of the underserved and in providing greater efficiency for some solo and group practices.”
Getting the Payers Onboard
The required traction for widespread implementation of truly integrated models will rest on outcome-based proof that oral health care lowers medical health care costs. As Holland notes, the measure of success that matters to the main drivers—the payers—is proof that when people are healthier, costs are lower.
The process of medical integration may therefore be sped up by traditional insurance companies, which have much to gain by supporting oral health. Dufurrena notes, “The big insurance companies like United Concordia, which have both dental and medical components, are finding that patients being treated on the dental side will save money on the medical side.”
Plunkett agrees. “If we can demonstrate in our unique integrated system that dental care definitely contributes to lower overall total health care costs, then our organization and other large national health care constituents will respond. KP is both payer and provider and therefore must weigh the patients’ best interest against the economics involved in serving them. We want patients to enroll in our program and choose to stay for their lifetime because we are providing a very different value to them. Our challenge is to follow through on our commitment to improve their total health, while providing a care experience that leads to a lifetime partnership with that member.”
It seems clear that the ability to provide the proof and implement the actions that would deliver the benefit payers want—lower costs—would need to be based on large studies. Dufurrena believes that DSO-supported dentistry is well positioned to implement integrated oral and medical health care. “DSOs have the ability to aggregate information and can have better communication between larger dental groups and physicians groups. They also have the capital resources to actually make that work, while traditional solo practitioners are generally limited to developing relationships with their patients’ physicians; they don’t have the records and communication systems.”
On the other hand, he says, the combined membership of ADSO, which sees about 30 million patients in a year, can put together the information available to show what works and what doesn’t to demonstrate best practices.
HealthPartners not only has the ability to aggregate and act on data, it also has a research institute. While individual data remains confidential, aggregate results are reported back to clinic teams including dental assistants, dental hygienists, dental therapists, clinic supervisors, and regional managers.
“The competence of the entire team is improved with this strategy,” Gesko says. “As an example, system-wide risk assessment for caries, periodontal disease, and oral cancer (which requires the collaborative effort of both dentists and hygienists) is reported regularly. Consistently, 90% of HPDG [HealthPartners Dental Group] patients in a category of moderate or high risk for caries, periodontal disease, and/or oral cancer are provided with appropriate interventions to mitigate this risk. Monitoring of this process of assessment and intervention is conducted in an ongoing fashion and providers are kept abreast of expectations regarding this measure.”
Because of shifting factors such as the ACA, the widespread recognition of the “perio-systemic connection,” and socioeconomic challenges that have permanently changed dental practice, the profession is often struggling to deliver services now seen to be more important than ever. These different models have economic and humanitarian implications in terms of costs and benefits to all concerned—patients, providers, and insurers.
The ideal, says Guyton, is having dental and medical practitioners come together to rally around patient needs and wants in new, unique, and collaborative group practice settings. “These groups will have unparalleled support services, while they simultaneously enhance the quality and efficiency of care, with clinicians practicing at the top of their licensure, so that all patients win regardless of the insurance they possess.”
Given the objective of improved patient care delivered efficiently and affordably to all segments of the population, it seems clear that there is much work to be done, maximizing technology—particularly patient health records—as well as the provider workforce, and perhaps, most importantly, partnership among all those involved.
Independence Meets Buying Power
Denver, Colorado, clinician Gary M. Radz, DDS, occupies what might be seen as middle ground between a traditional private practice and a DSO-supported practice. Although he owns the cosmetic-focused dental practice he has built over nearly 2 decades, he is able to benefit from his affiliation with more than 300 colleagues who subscribe to the Texas-based dental alliance Smile Source. This nationwide network of private practice dentists, which has been evaluated and approved by the ADA CERP as an official continuing education provider, enables him to compete in the new dental economy because it gives member practitioners the bargaining power to more affordably access the equipment and resources they need to compete with the mega group practices in the new dental environment.
“SmileSource is a community of like-minded independent dentists who have dedicated themselves to working as a group to be able to compete in a changing health care market. Not only do we see the economic benefits of working together, we benefit from learning best practices from one another, can maximize marketing ideas and costs, and we have created an continuing education program to help our doctors and their teams bring the latest materials, techniques, and technology to their patients,” says Radz.
Technically a franchise, Smile Source helps independent dentists thrive in the current marketplace, according to Carvin D. Joshua, marketing manager, Smile Source. “Our goal is to provide the benefits of a DSO while the doctors remain completely independent. They retain control of all aspects of their practice while taking advantage of benefits available to them through a membership fee that gives them access to a group of executives, continuing education events, and deeply discounted products and services via ‘the leveraged buy.’”
Joshua suggests this model actually helps preserve independent dentistry, including an avenue for new grads to gain experience and a paycheck working with an independent established dentist rather than a corporate practice.
Smile Source President Trevor C. Maurer points to his company’s tagline to underscore the value of maintaining the traditional practice model despite challenges posed by the current economic environment. “‘Enriching lives by enabling independent dentists to reach their full potential’ is in the best interests of both practitioners and patients,” he says.
Because 90% of Kaiser Permanente (KP) NW subscribers are covered both medically and dentally, it is possible—but not yet seamless—for providers to access accurate information about the dental patient’s medical conditions and medications. “This currently involves multiple systems with the added manual process required to access separate platforms,” says Plunkett.
This process will become much easier in 2016, he says, when KP plans to launch the Wisdom Dental module within EPIC, the largest national EMR vendor. “EPIC is currently utilized by Kaiser Permanente in all other regions, so the migration will also be a key step in facilitating a possible national expansion of the unique integrated capability now found only in the NW.” Similar to KP, HealthPartners includes a medical group and comprehensive medical plan as well as a dental group and dental plan. Gesko says HealthPartners, which already has a robust electronic records system, will complete its transition to fully integrated records with the Wisdom module in 2017. “We’re very excited about the move in this direction because our medical group, which includes 1,500 physicians, is significantly larger than our interdisciplinary multi-specialty group practice, which consists of 75 dentists practicing in 24 HealthPartners dental clinics across the seven-county greater Twin Cities metropolitan area and serves more than 125,000 patients.”