Learning from the Convergence of Medical and Dental Insurance: Who’s Driving the Change?

Ronald E. Inge, DDS, Delta Dental, Missouri

Will Hinde, West Monroe, Chicago, IL
Benjamin Baenen, West Monroe, Chicago, IL
Kristin Irving. West Monroe, Chicago, IL
Chris Stenzel, MBA, Kaiser Permanente, Oakland, CA
Edward A. Murphy, MBA, Life and Special Ventures

The webinars in the Continuum series organized by the Santa Fe Group have pointedly illustrated the losses —to science, to the public’s health, to potential savings in healthcare costs resulting from the long separation of dentistry from medicine in science, education and practice. The fourth webinar extends the discussion to the business of healthcare. How has that separation affected the health insurance industry and what gains in business growth and the health of those insured are possible when medical and dental plans converge.

Dr. Inge’s opening remarks reminded the audience that the idea that oral health is essential to overall health was highlighted in 2000 and in 2006 Aetna Insurance had even coined the phrase medical-dental integration. So why, he asked, with the hundreds of articles touting the benefits of including oral health in the treatment of many diseases is it taking so long for integration to happen? The speakers he introduced would ask how insurance decision makers have been changing their views on integration, and conclude with examples of medical-dental insurance convergence.

First was Will Hinde from the business consulting firm West Monroe who said he and colleagues, Benjamin Baenen and Kristin Irving have been meeting with insurance executives for some time and published the results of survey they had conducted in 2017 indicating that 60 percent of dental insurers agreed that there was a shift occurring and that there would be a significant decrease in stand-alone dental plans in the next 3 to 5 years. However, 24 percent of the dental payers said they were proceeding with “business as usual” and 60 percent said they had no future action plan. On the medical side, 68 percent of survey respondents said they were already offering some dental benefits.

But, as Mr. Baenon next reported, a repeat survey conducted only two years later showed that 96 percent of respondents now believed that dental and medical plans would converge although it was uncertain what the dual coverage would look like (bundled as one package? Independent entities?) The number of medical plans offering some dental coverage had increased to 80 percent and dental coverage for adults was included in 48 percent of the plans, double the number reported in the earlier survey. Fifty-six percent of the dental payers now said they were seeking partnerships with medical plans, while conceding that medical plans had a competitive advantage.

Kristin Irving followed Mr. Baenon’s data discussion by outlining the kinds of strategic thinking taking place now as decision-makers consider how to create integrated plans that will retain loyal members and win new ones. West Monroe urges building a strategy that exploits the best new digital technology, including machine learning and artificial intelligence leading to efficient administrative and care management tools, such as a user-friendly patient portals where a member can schedule appointments or ask questions about coverage and claims. Overall, the intent should be to reduce paperwork. The provider network also needs to be protected and communication between dental and medical practitioners facilitated in order to realize the health benefits and cost savings that integration makes possible.

A number of those principles are built into the design of Kaiser Permanente’s ventures into medical-dental integration, as described by the next presenter, Chris Stenzel. Kaiser Permanente (KP) is the country’s largest non-profit health insurer, he noted, with a mission ‘to provide high quality affordable health care services and improve the health of the members and communities we serve.” Headquartered in Oakland, California, KP employs 23,000 physicians and 63,000 nurses working at their 39 hospitals and 723 medical offices, altogether serving 12.5 million members.

Their integrated medical-dental program at KP Northwest operates in Oregon and southwest Washington where 162 dentists are employed at 21 offices (some co-located with KP medical facilities). Dentists are salaried, relieving them of the pressures of building a practice and allowing them to concentrate on quality patient care. The program has been functioning for 45 years— time to hone its strengths and measure the results of its organizing principles, which Mr. Stenzel described as “getting all of it together.” That means that each member’s electronic health record includes demographics, the complete medical history, lab tests, preventive interventions, treatments, etc., all documented with additional space for the complete dental history that includes diagnostic codes and procedures. It also means togetherness in the specialties, so that the dental offices house general dentists along with endodontists, periodontists, and other specialties, facilitating communication and collaboration. Collaboration among physician specialists and between physicians with dentists is also built into the system. The result is a high level of transparency and an intense focus on the total health of patients. What is particularly noteworthy is the degree to which the program is able to close care gaps: When a caregiver notes that a patient needs referral for a cancer screening test, blood pressure control or other health issue, the problem is discussed with the patient, annotated on the record with referrals and follow-up details and outcomes recorded. A key measure of success of that approach is an estimated annual $11.1 million reduction in future medical costs for patients with diabetes or cardiac disease who use the dental services, Mr. Stenzel said. Overall, he commented that KP patients who use both medical and dental services “weigh less, smoke less, and visit hospitals or emergency departments less often than patients who use only medical services.”

In September 2020, KP launched a second model of integrated medical and dental care insurance. Called Health 360, it represents a partnership between KP and Delta Dental of Washington state. The system is sold as a single product, with the colors and logos of the partners shown under the new name. As with KP Northwest, Health 360 aims to improve the total health of members. The system operates under a single simplified and streamlined administrative and management plan offering comprehensive and cost-effective coverage. Importantly, the plan actively promotes oral health and prevention interventions in all its messaging and offers additional dental cleanings at no extra cost to patients with diabetes or heart disease, and to women who are pregnant.

The final presentation of a model medical-dental convergence plan was Edward A. Murphy, MBA, whom Dr. Inge introduced as a veteran in the field. Indeed, Mr. Murphy is a Board member of the Harvard initiative for the Integration of Oral Health into Primary care. He said that he came out of retirement 10 years ago to join Life and Special Ventures, a wholly owned specialty insurer of several Blue cross health plans, to work on the dental side of integration plans. He described Dental4Health, the model that LSV has developed in partnership with Arkansas Blue Cross Blue Shield, as one similar to the KP-Delta Dental of Washington Health 360 plan, in that it targets high-risk patients with chronic conditions such as diabetes and coronary artery disease. The patients are identified by the standard international Classification of Disease codes in their Blue cross eligibility listing. LSV then offers them enhanced dental care prevention and treatment services at no extra cost and not assessed against the plan’s annual maximum. The plan uses a variety of outreach programs to communicate the message that the services are an evidence-based means of improving the patient’s oral health and lessening the severity and consequences of their chronic condition. When these patients meet with physicians in the Blues network, the doctors can “close the care gap” by referring the patient to LSV’s dental network. A key element facilitating the interprofessional communication and referral is an electronic health record detailing the patient’s complete and up-to-date medical and dental data. The physician’s outreach is incentivized by rewards if the high-risk patient is compliant and follows up with a dental appointment and treatment regimen. Incentives for dentists are also planned, in terms of recalls and follow-up. Care Management teams employ a variety of strategies to improve compliance.

That integration pays off for compliant patients was shown in Mr. Murphy’s concluding slides summarizing 5 years of the Arkansas data, independently analyzed by biostatisticians at the Mayo Clinic. Overall, the plan resulted in an estimated annual 30 percent reduction in hospital costs for compliant patients with either diabetes, coronary artery disease or both. Comparisons between compliant and non-compliant patients showed no intrinsic differences between them, so that the savings were not due to factors like greater care-seeking behaviors by the compliant patients. The efforts of care management teams were also shown to be effective since the percentage of compliant patients vs. the non-compliant increased from 42 to 57 percent over the 5-year time period.

There was time for a few audience questions which Dr. Inge fielded for the remainder of the webinar. The first questions concerned reimbursement and how dentists feel about being salaried under integrated care rather than the traditional fee-for-service payments in a solo practice.

Chris Stenzel addressed this, remarking on how much salaried dentists enjoyed the collegiality of their new role. They appreciated interacting with colleagues, the high technology in use, and the focus on care, freeing them from haggling over insurance and billing. He said that when openings for dentists became available there were more than 10 applicants for each opening.

Addressing the West Monroe group, Dr. Inge asked how important to consumers was the availability of a medical-dental patient portal? Will Hinde said that they had not asked that question directly, but anecdotally he saw an uptick in its favor.

What did the panel think were the chief catalysts for integrated care? The value proposition was the initial response – the idea that overall health could be improved, and health costs reduced) – and considered one of the chief drivers of integration. Increased collegiality was again mentioned, with contacts between medical and dental professionals resulting in dentists being seen as “oral physicians” and peers. Mention was also made of the growing importance of Health Information Exchanges, where large electronic data sets of health information are assembled for access by providers and consumers enabling identification of care gaps that could be closed and paid for through integrated care. A push for integration is also coming from large carriers who see integration as a driver of growth.

Has Covid affected plans? The panel agreed that the pandemic has been a major disruption. It has also inspired more than idle curiosity about integration, but actual budgets considering ways to generate healthcare savings by providing care at the dental chair.

Final questions concerned the role of dental hygienists in the dental network. The answer was of course dental hygienists are valuable. They are the ones providing the preventive services of dental cleanings and scaling and root planning for high-risk patients. And finally, does dental care for patients with chronic conditions just push their problems down the road until later in life? Here the answer, from Mr. Murphy, was clear. By providing dental care we are improving health and reducing co-morbidities, he said. For patients with the targeted conditions, the provision of inexpensive dental treatments on a recurrent basis, the returns are continuous and prevent healthcare costs from escalating.

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