Eliminating the Medical/Dental Care Divide

My friend, Michael, an otherwise healthy U.S. Air Force musician who passed his entrance physical, endured basic training and was subject to regular military physicals, became a cardiac patient. Infection introduced through his compromised gums caused endocarditis that damaged his heart valves. Had his gums received proper attention, he might still have a normal life expectancy without disability and with lower medical expenses.

Ten-year-old DaShawn Driver was diagnosed with six abscessed teeth in September 2006. He and his twelve-year-old brother, Deamonte, qualified for dental benefits under Medicaid, but their mother, Alyce, struggled to find a dentist and oral surgeon to treat DaShawn. Surgery finally scheduled for January was canceled because the Drivers lost their Medicaid coverage, possibly because paperwork was mailed to a homeless shelter in which they no longer lived. Meanwhile, Deamonte came home from school complaining of a headache. He was treated at the Southern Maryland Hospital Center’s emergency room (ER), leaving with medications for a headache, dental abscess and sinus issues. His condition worsened, and within two days, Deamonte was admitted to Children’s Hospital to undergo emergency surgery. Bacteria from the abscess, doctors said, had spread to his brain. One night, after a combined eight weeks in two different hospitals and an additional brain surgery and a tooth removal, Deamonte asked his mother to pray for him. He died the next morning.¹

ORAL HEALTH AND CHRONIC CONDITIONS

These stories are not exceptions. Oral problems impact overall health and, therefore, the cost of medical care. Moreover, chronic diseases and health conditions can affect oral health, potentially creating a vicious cycle. Among these conditions are chronic obstructive pulmonary disease, cardiovascular disease, pregnancy, autoimmune disease, substance abuse and health care-associated infections.² Some of the impacts of dental concerns on medical conditions, the medical conditions’ impacts on dental concerns, and costs are:

1. Pregnancy’s hormonal changes may result in periodontal gum disease. Enzymes present in more advanced cases of periodontitis may trigger labor, resulting in high costs for pre-term labor abatement or premature deliveries.^3,4
2. Some medication regimens may cause xerostomia (excessively dry mouth), which if untreated, can cause periodontal disease. This condition is especially difficult to manage among elderly and nursing facility confined patients.⁵ Because this population is comparatively edentulous (toothless in part or whole), they may also require a prescription rinse to reduce swelling and stomatitis (lesions) under their dentures. Compromised gums are potential entry points for infection and overall deterioration of health.⁶
3. Diabetes management is difficult, especially when medications and the disease itself affect the gums.^7,8 In turn, receding gums and inflammation impact insulin resistance levels as well as what is eaten, making diabetes management more difficult and costly. It is estimated that one-third of the 30 million diabetics in the United States suffer from the even more serious periodontitis.⁹ In newly diagnosed type 2 patients, early periodontal treatment may give rise to net medical savings approaching $1,500 over two years and a possible additional net savings in subsequent years.^10,11,12 While the periodontal issues of diabetics may seem self-inflicted, the truth is that periodontal issues and diabetes are intertwined medical conditions. Diabetes is just one of many chronic diseases that impact dental health and are affected by dental concerns.¹³
4. Infections introduced through the gums may result in bacterial endocarditis, damaging valves of the heart. Patients with certain heart conditions are more susceptible to these infections and, therefore require more attention to precautions and care of their oral health. Productivity, longevity, disability and high medical costs remain issues throughout an endocarditis patient’s remaining, shortened life.^14,15,16

TREATING THE WHOLE PERSON

Dental issues are more than a cosmetic concern. Also, as noted previously, oral concerns may not necessarily be purely a result of dental neglect. As a society, we have ignored or disregarded the enormous toll—measured in terms of overall health, emotional health, longevity, quality of life, productivity and financial cost—caused by separating oral health from other physical health.

Failure to treat the whole person with intertwining medical concerns affects the entire population, particularly the poor. The poor often hope to access dental help through the ER. Emergency treatment rarely addresses dental issues directly; instead, pain medications and antibiotics are prescribed with referrals to dental providers. Sometimes a tooth is extracted. Consequently, return visits account for an estimated 25 percent of the $1.6 billion spent annually on dental outpatient ER visits. This excludes medical charges for which dental was not coded as the underlying cause including, for example, treatment for depression arising from real or perceived responses to poor oral health in personal or employment situations.¹⁷

ACCESS AND AFFORDABILITY ISSUES

Dental access and affordability affect the working poor, unemployed, retired, disabled, homeless and immigrants. Medicare provides no dental coverage to its covered population of elderly and certain disabled individuals. If available at all, adult Medicaid dental benefits are inadequate in many states. In addition, dental access remains an issue for impoverished children nationwide despite the availability of federally mandated dental coverage through Medicaid and the Children’s Health Insurance Program (CHIP). In particular, appropriate treatment is often delayed due to willing provider shortages at the lower reimbursement levels offered by Medicaid.¹⁸

Access to dental care is especially limited for the 25 million disabled or elderly people living in rural communities. If available at all, transportation services provide limited access to services that may be far away. Moreover, rural communities often do not fluoridate their water despite the fact that caries may be reduced by 25 percent with fluoridation.^19,20,21

EXPANDING ACCESS TO DENTAL CARE

Thankfully, some progress has been made to assist the poor. The Veterans Administration is working with dental schools to provide free services in 12 states. “Community Dental Health Coordinators,” dentists who return to serve their own underserved communities, have been funded in eight states. The Give Kids a Smile volunteer outreach and other programs provide free annual screenings, basic care and referrals to underserved children. Some states provide screenings and fluoride treatments within underserved school populations via community health workers, school nurses and hygienists under dentist supervision. Approximately 75 percent of Federally Qualified Health Centers (FQHCs) include dentistry within the patient medical home.^22,23 Some Medicaid plans offer much more adequate reimbursement levels at the 75th percentile of market rates, which encourages higher volumes of services that dental services providers can afford to provide.²⁴

To bridge the gap between dental and medical care, universities now train medical students to perform oral exams in order to refer dental issues to dental providers. As a result, more primary care practices include oral screenings and referrals to dentists for all patients. Without the means to pay for dental follow-up, however, dental services may not be sought whether or not the patient is on Medicaid or Medicare, or part of the working poor who qualify for neither program.

The American Dental Association’s Health Policy Institute has been researching ways to avoid the ER and promote dental health within Medicaid and Accountable Care Organizations and among the public. Perhaps its research and outreach to the medical community will lead to greater collaboration among medical and dental professionals to achieve better overall health.²⁵

The World Health Organization’s 2003 Report notes: “Oral health is integral to general health and quality of life.”²⁶ How can general health and quality of life in the United States be optimized when 40 percent of the adult population has no dental coverage, approximately 33 percent of adults in any given year avoid the dentist’s chair, and 50 percent of the adult population suffers from dental infections at any given time?²⁷

CONCLUSION

Progress thus far—whether increasing access to dental care or bridging the gap between medical and dental professionals—does not adequately address care of the whole person. Had the medical–dental divide not existed, Michael’s endocarditis and Deamonte Driver’s premature death might have been avoided. A more comprehensive, all-participants-on-deck approach is needed.

Actuaries can be part of the solution, utilizing our understanding of financial implications and mathematical relationships, research capabilities and quick assimilation of interrelationships. We should examine possibilities of plan designs that recognize the relationship between oral and overall health. That approach might include bringing medical and dental benefits under the umbrella of medical plan design. It definitely calls for new design approaches that challenge current mindsets. Actuaries can effect change among insurers, regulators, legislators, the health sector and the public by drawing attention to areas for potential financial savings and extending healthy lives.

The Society of Actuaries’ mission statement calls us to “improve financial outcomes for individuals, organizations and the public.” Removing the divide between medical and dental benefits is one step that could help answer this call. As actuaries who desire to leave a legacy, we must think beyond what has been and move into the future with ideas that will make a difference.