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National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Global Forum on Innovation in Health Professional Education; Cuff P, Wouters M, editors. Whole-Person Oral Health Education: Proceedings of a Workshop. Washington (DC): National Academies Press (US); 2024 Oct 18.
Whole-Person Oral Health Education: Proceedings of a Workshop.
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BOX 3-1
Key Points Made by Individual Speakers.
The next workshop session aimed at providing attendees and speakers with a better understanding of what a value proposition in oral health could look like. Robert Weyant, associate dean of Dental Public Health and Community Outreach at the University of Pittsburgh, chaired the session. In his remarks, he framed the upcoming presentation and discussion saying, “We will embark on a journey to examine the profound impact of oral health on diverse vested interest groups beyond the traditional lens of dental care.” He asked attendees to keep in mind the value of prevention, a core part of patient care and system design. The value of disease prevention can lead to lower costs, improved health and well-being, program sustainability, and enhanced quality of life, he said.
VALUE PROPOSITION FOR ORAL HEALTH
Richard Berman, associate vice president for strategic initiatives for innovation and research at the University of South Florida, described a value proposition as it relates to oral health. “It’s that thing that is so obviously important ... why isn’t it happening?” he asked. He went on to answer his question with “[It is] because people don’t value it the same way you value it and the same way you see it so obviously.” Berman emphasized that different people value oral health differently. For a value proposition in oral health, one would be looking for a sustainable solution that will make an improvement. It is important to determine who the customer is. For example, he said, if someone were to build a startup selling a new product, it would be important to realize who the customer is. If the customer does not see value in the new product being offered, it will not sell, and the startup would not be sustainable. Therefore, the value proposition should look for a sustainable solution that improves the oral health of the population.
Berman discussed a business model with various segments, which is used by the National Science Foundation and many venture capital groups to decide what new projects or programs to fund. This business model is also being taught in universities. To understand the value proposition, it is important to realize that it caters to the requirements of a specific customer segment, and therefore based on those segments’ differentiated needs and or behaviors. Rather than creating an intricate business plan, leaders often summarize their hypotheses in a framework called a business model canvas. Essentially, this is a diagram of how a company will create value for itself and its customers (Figure 3-1).
FIGURE 3-1
The business model canvas. SOURCE: Berman presentation, February 15, 2024. Illustration created by Strategyzer AG (strategyzer.com). This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 Unported License. To view a copy of this license, (more...)
In health care, there are three main vested interest groups or segments, he said. The first are the patients, the clients, or the community. This goes back to the earlier-mentioned statement of “you cannot do something for us, without us.” For these groups, it will be important to ask what people with physical or cognitive disabilities or conditions need. Aspects to think about in this respect are payments, access to a place, relief from fear or anxiety, and whether there is access in the evening or only during the day. There is a need to understand who the patient or end user or community is and consider language, money, culture, and other factors, he said. To determine the answers to these questions, Berman stated that it is essential to go to patients and clients and ask open-ended questions. The most important part of the value proposition is to understand from those who have a vested interest in the issue what their problem is that the value proposition aims to resolve or improve.
Berman noted that the second vested interest group in health care consists of providers and educators. For this group, it is important to understand what their barrier or problem is and what their gain is. Again, it is critical to ask this group what is important to them to ensure that the proposed solution meets their issue. Finally, the third group is the payers, which can be insurers, Medicare, Medicaid or other government programs, and foundations. For this group as well, he said, it is important to understand their pains and gains.
Berman finalized his explanation of the value proposition, confirming that one would be looking for a value proposition that solves pain or enhances gains for all the interested parties (Figure 3-2). When there is a clear understanding of customer satisfaction for a product or service, a solution can be devised that matches the value proposition, which results in the building of a sustainable model.
FIGURE 3-2
The value proposition should solve pains and enhance gains for each vested interest group. SOURCE: Berman presentation, February 15, 2024.
Perspectives from Groups with a Vested Interest
To better understand the oral health value proposition, four speakers presented their views on the pains and gains from the perspectives of their different groups: (1) persons with disabilities, (2) providers and educators, (3) payers, and (4) policy makers.
Persons with Disabilities
The persons with disabilities group member, John Kemp, is president and chief executive officer of the Lakeshore Foundation and is part of the people with disabilities community. He discussed projects on accessible oral health in response to the question: What better ways are there to serve people with disabilities for improving oral health, and thus, overall health?
Kemp said that asking for equity in health care distribution is important. Disability has now been recognized as a health disparity by the U.S. Department of Health and Human Services (NIH, 2023). To improve this disparity, it is essential to look for respect and inclusion in all aspects of care, he said. Inclusion requires a different way of serving people, and the minimum should be access and equality overall. In the community, there is the issue of accessibility of the dental office. Further, he emphasized the need for culturally competent people to serve the needs of people with disabilities, which requires education and training. The practice of not accepting people with disabilities into dental practices and referring them to the hospital for anesthesia, which is currently often done, is the easier way, Kemp said, but it is inhumane and inappropriate.
Another accessibility issue is that many dental offices use portals to access information. In order for this to work, the patient has to be able to access the portal, and have Internet service, phones, and other tools, which can be a barrier in terms of costs or usability. Additional barriers, Kemp said, include the way providers communicate with patients and clients. This should be done in an accessible format, but this is not always the case. For example, when video is used as an instructional tool, it would be important to also have it captioned so it is accessible, and people can make choices on how they receive the information.
There is also the issue of culture. While 17 percent of the population with disabilities are born with the disability, the majority—83 percent—acquire the disability through injury, illness, accidents, or other events. To these people, the disability and its barriers are new, as they are to their family and caregivers. Therefore, it can be challenging for this group to negotiate their needs and navigate the system, Kemp said. He noted that people with disabilities now demand the respect that is essential for them to ask for equality and equity; a heightened acceptance of human differences is essential for this.
Finally, Kemp noted some barriers that exist for people with disabilities receiving oral health preventive care. For instance, to get to a dental office, barriers may exist in terms of transportation, accessibility of the dental office, and acceptance by dental providers. People might make it to a dental office and get turned down after having spent money and time to get there. Another barrier is communication, with some in health care talking condescendingly to people with disabilities. For people with disabilities, these types of accessibility barriers provide a silent message that they are not being welcomed, said Kemp. In closing, Kemp emphasized that “what we’re really looking for is respect and inclusion in all aspects.” He added that persons with disabilities are not asking for more than their fair share, just equity in the health care distribution that, in this case, would make the dental office fully accessible and free of barriers for all people.
Providers and Educators (Interprofessional)
As a physician with a rural practice background, Mark Deutchman, the associate dean for rural health at the University of Colorado, presented virtually about what he sees as the value proposition for health care providers and educators, with particular focus on interdisciplinary practice and education, and on persons with disabilities.
Deutchman first discussed the value proposition for providers. For them, he said, there is the importance of improved health through prevention. Providers are looking for ways within the scope of their care and abilities to prevent disease and disability. Oral health is an example of a tool that crosses essentially all body systems. Deutchman underscored the importance of the link between oral health and overall health and that much of oral disease is preventable via personal behaviors. When this is understood, he said, it becomes intuitive that mechanisms to promote oral health and prevent dental and related diseases should be adopted. Examples include looking for ways to connect virtually for counseling patients about what they can do for themselves and performing interventions available within the practice environment and scope of care. Although Deutchman is not a dentist, he can look in the mouth and identify gum disease. He can also teach students to look for spots that might identify dental caries. Furthermore, he can apply fluoride varnish, and soon he may be able to apply silver diamine fluoride; train students, residents, and fellows; and collaborate with other health and nonhealth professionals so everyone is able to perform these tasks.
For health care providers, said Deutchman, something like fluoride varnish for kids is an attractive intervention because it works and because it is preventive. It is also important for health care providers to realize that when treating people with disabilities and chronic illness, prescribed medications can adversely affect oral health.
Deutchman then shifted to say that health care providers already do things such as motivational interviewing with people regarding tobacco, seat belts, helmets, and reproductive health, and these same skills are transferable to talk about oral health. The skillset is there, he asserts. Once the knowledge and desire to include prevention and health promotion messages to people and populations is in place, change can happen; however, Deutchman acknowledged that there are barriers. Change does not happen without administrative buy-in, and all providers have time constraints, he said. This means that administrators who do the hiring and determine schedules must value the messaging as well.
For educators, the value proposition constitutes a curriculum opportunity for interprofessional education although a major barrier to making this happen is the already overflowing curriculum. As a result, it becomes hard for educators to introduce a new module, subject, or class, he noted. However, since oral health crosses various subjects and disciplines (e.g., anatomy, infectious disease, nutrition, aging, special needs, disabilities, and metabolism), the topic could be introduced by, for example, asking a simple question like, “What is Streptococcus mutans?” This is how students could start to learn about oral health while also providing interprofessional, experiential learning opportunities. If students learn with and from colleagues from other professions while they are in training, concluded Deutchman, there is a better chance they will practice collaboratively and use the interpersonal skills they acquired during training after graduation.
Payers
Randi Tillman, executive dental director, Health Care Services Corporation (HCSC) attended virtually and discussed the value proposition for insurers. She noted at the start of her talk that experience has taught her that value is in the “eyes of the beholder,” and depends heavily on the individual’s perspective. As someone who works in insurance, Tillman shared her views from that lens saying, “Yes, of course we are interested in the [return on investment], but we are also interested in our public image and in gaining a competitive advantage.” For insurers, it is important to manage health care costs—both medical and dental—for their customers, Tillman said. Their customers are employer groups, but insurers are also committed to improving overall health and are aware that they are selling very personal products.
As an organization, Tillman said, it strives to be an industry leader in oral health and medical dental integration, which means the company wants to learn how to do things better. Many patients have both medical and dental coverage with HCSC, allowing for integrated care. As an insurer, HCSC can provide additional dental benefits, which can help manage both medical diagnosis and the oral environment. This does not typically result in any extra effort or cost for the patient, said Tillman. HCSC tries to incentivize the use of these additional benefits by their clients. For instance, HCSC staff can remind patients with diabetes and cardiovascular disease to maintain their oral health by sending postcards and providing phone call reminders. The same goes for dental patients who the company knows have chronic medical conditions; they too can receive company reminders.
Tillman explained that when employers are looking to purchase medical and dental insurance, the most significant cost is on the medical side. Therefore, she said that an argument can be made that if good oral health is maintained, the costs on the medical side can be reduced. This has been backed by some research, Tillman noted, that has shown that patients with chronic medical conditions who receive regular preventive dental care experience better medical outcomes. However, she also noted that exacerbation of chronic illness is multifactorial, which means that poor dental care can be a contributor, but it is often not the sole contributing factor. Tillman concluded by saying that payers have a role to play in making a meaningful contribution to the management of oral health and medical health, as well as overall integration—a key part of a payer’s value proposition.
After finishing her remarks, a question was posed whether teledentistry could be used for preventive dental checks for bridging the gap in oral health care use in children. Robert Weyant noted that there is variability in teledentistry policy and the ability to use it between states, which poses a barrier. John Kemp added how essential it is that any technology also be accessible to parents who are deaf or need someone to type for them. Whichever way it is delivered, he noted, the technology would have to be accessible to all. Michael Helgeson said that telehealth can be great for many different groups of people. For dental care, a large amount of work can be done where the person lives, where they go to school, or where they work. This can solve lots of problems, and advice can be provided to patients. Providing care in the community lifts many of the barriers discussed for people with disabilities in getting to dental offices although also using telehealth before an office visit can save money and time and create better patient experiences, he said.
Policy Makers
Natalia I. Chalmers is the chief dental officer at the Office of the Administrator at the Centers for Medicare and Medicaid Services (CMS). As a pediatric dentist and oral health policy expert, Chalmers guides CMS in advancing oral health in Medicaid, the Children’s Health Insurance Program (CHIP), Marketplace, and Medicare. In her talk, she highlighted the effect of the programs at CMS that provide health coverage for close to 160 million people in the United States, of which 88.4 million are insured through Medicaid and CHIP (CMS, n.d.a). CMS is committed to serving the public as a trusted partner and steward, said Chalmers. CMS is dedicated to advancing health equity, expanding coverage, and improving health outcomes for all people including persons with disabilities. More specifically, Chalmers regards CMS as a steward of value-based payment models while also managing a variety of crosscutting initiatives that are multiyear endeavors. One of these initiatives was launched in the past year and focuses on oral health. The initiative considers every opportunity to expand access to oral health coverage using existing authorities and health plan flexibilities.
When people do not have access to a dental care delivery system, they will end up in the broader health care system for emergency care (Figure 3-3). The dental care delivery system depicted on the left of the figure, shows that many people in the United States regularly visit their dentist, often on a 6-month schedule, said Chalmers, thereby limiting or avoiding the need for emergency dental care. However, further to the right are a variety of scenarios where emergency care is used, such as when a child with a painful tooth abscess is brought to the emergency room for care. Some people are repeat users of emergency care—shown as circular arrows—while others who are admitted for a variety of nondental conditions also suffer from poor oral health that can negatively affect their overall health outcome. Chalmers then pointed to the right side of the figure saying ambulatory surgical clinics and urgent care clinics provide additional points of entry into the health system and could be opportunities for preventing oral disease and promoting oral health. These messages can also be spread through community organizations such as schools and recreational facilities.
FIGURE 3-3
Where patients present with oral health needs. SOURCE: Chalmers presentation, February 16, 2024. Image created by Chalmers.
Further underscoring the financial burden of treating people with dental disease versus preventing it, Chalmers asked, “Is this the best use of resources given the high cost of care in the emergency departments and the low cost of oral disease prevention?” She asked the audience to realize the effect of poor oral health on patients who are admitted for other surgeries; financial burden is not only about the dental problem driving people to hospital emergency care, but it is also that poor dental health can affect surgical outcomes.
Chalmers noted that coverage is only the first step; getting to and finding providers that can address the needs of people is more complicated. Another barrier is the health information technology divide. It can be hard for small-scale dental practices to overcome that challenge and connect to a large health care system or an electronic health record. Therefore, providers in those settings must rely on the medical information that the patient recalls. This might not be very accurate, and patients may not realize the link between certain conditions and oral health. For instance, the use of some antidepressants can result in xerostomia (dry mouth), which affects oral health.
Diagnostic coding was mentioned earlier as a barrier, and there is no standard of practice. Chalmers said it is important that all health care providers speak the same language to truly understand each other. These factors all affect the coordination of care, she said.
Referencing data from the Health Policy Institute, Chalmers showed progress made for children. However, the data show a gap between children who live below the federal poverty guidelines and those who do not in terms of how often they visit the dentist. This gap is closing, but the difference is still approximately 20 percent, and the gap is even bigger for older adults (Yarbrough and Vujicic, 2019). Chalmers then referred to data from 2018 showing that some people only see a dentist (8.6 percent), some only see a physician (34.4 percent), some see both (37.1 percent), and some see neither (19.8 percent) (Manski et al., 2021). If the dentist is the only access to care, there is a huge opportunity to do more medically, such as screening for blood pressure or diabetes, she said. Data show that coverage matters for these issues, but even when it is limited or not there, people end up needing dental care (Manski et al., 2022).
Chalmers followed up her comments with National Health Expenditure data on dental health costs showing such costs represent 4 percent of the total expenditures, or $165 billion (CMS, 2023). On average, the out-of-pocket spending is approximately 40 percent, while the rest of health care is around 9 percent. For Medicare beneficiaries in the community, this percentage is even higher. Chalmers said that this is one of the biggest barriers to accessing dental care.
Chalmers then discussed definitions for value-based care and associated terminology as defined by the CMS Center for Innovation (CMS, n.d.b). She noted that it is important to define what is meant by accountable care—a person-centered care team takes responsibility for improving the quality of care, care coordination, and health outcomes for a defined group of individuals, to reduce care fragmentation and avoid unnecessary costs for individuals and the health system. Care coordination is the organization of an individual’s care across multiple health care providers. Integrated care can be defined as an approach to coordinate health care services to better address an individual’s physical, mental, behavioral, and social needs, while person-centered care consists of integrated health care services delivered in a setting and manner that is responsive to individuals and their goals, values, and preferences in a system that supports good provider–patient communication and empowers individuals receiving care and providers to make effective care plans together.
Chalmers defined value-based care as designing care so it focuses on quality, provider performance, and the patient experience. Therefore, the value in value-based care refers to what an individual values most. From there, it is possible to design care coordination so it achieves the target of improved outcomes, she said.
The CMS Innovation Center develops and implements payment and service delivery models (pilot programs) and conducts congressionally mandated demonstrations to support health care transformation and increase access to high-quality care, said Chalmers.
Chalmers noted that at the heart of value-based care is reliable measurement. Additionally, it is essential to understand that barriers to care and the health goals of individuals can only be uncovered by talking to the individuals themselves. She argued that health goals cannot be assumed and can only be uncovered by listening, particularly to caregivers and persons with disabilities who are the recipients of the care.
An online audience member asked Chalmers to share her thoughts about mid-level dental providers that could be implemented in dentistry in various settings. Chalmers said that such decisions are made at the state level. State governments decide who is eligible to practice in their states. Another virtual participant asked how the oral health field could become accessible to disabled practitioners. Chalmers noted that it is important to understand how disability is defined. For instance, providers, both dental and nondental, struggle with mental health challenges and some may have some level of disability. Helgeson added that dental practitioners can limit their practice in different ways to account for their various kinds of disabilities.
DEMONSTRATING THE VALUE PROPOSITION FOR PERSONS WITH DISABILITIES
Mark Wolff, dean of Penn Dental Medicine, moderated the session exploring an oral health value proposition for persons with disabilities. He opened by describing the program at Penn Dental Medicine in which students spend 20 percent of their time in the community doing dentistry in an interprofessional medical setting, and 10 percent of their time at Penn Dental Medicine’s Center for Persons with Disabilities. The goal of the program is to learn from and with other professions while becoming comfortable working with people who have a variety of different disabilities. A goal of the program is for students to learn how to deliver the best care and communicate with caregivers and patients so 90 to 95 percent of individuals coming to the center can be treated without sedation or general anesthesia. The personalized care suite sees 8,000 patients per year in that facility, Wolff said, and Penn Dental Medicine trains 200 dentists a year and additionally provides continuing education to tens of thousands. The school has immersion projects with individuals who can come to the school and learn how to deliver this care after taking continuing education.
For treatment, Wolff argued it is very important to discuss equity and equality in treatment. Overall, he said, real change is needed, and it should not be the goal to make a rotten system a bit less rotten. CareQuest recently published outcomes associated with oral health showing that oral health affects activities of daily living, how people eat, concentrate, sleep, and learn (Heaton et al., 2024). When it comes to value-based care, Wolff noted it is also essential to discuss productivity hours lost due to unexpected emergency dental visits and oral pain. The report estimated 13 million adults lost 187 million productivity hours annually. Further, 5.7 million parents and caregivers lost 243 million productivity hours caused by unexpected emergencies. Therefore, Wolff said, it is important to consider the real costs of poor oral health.
Wolff then asked, “Where are people with disabilities going to find care?” He said preventive care is often not covered by insurance or Medicaid programs. Penn Dental Medicine writes off approximately $3 million annually in preventive and supplemental visits that are not covered. There are other financial costs as well, such as emergency room visits and care in operating rooms, but also the cost to society when opioids are prescribed for mouth pain that lead to addiction. Wolff emphasized that including these sorts of costs should be considered when talking about value-based care. The cost is not the payment of $18 per patient for providing fluoride varnish to prevent decay, he argued, and value-based care should take the real savings seen throughout the system and distribute them back to caregivers and the care system to reduce overall cost. However, Wolff acknowledges that this will be very challenging to do.
Creating Sensory-Adapted Dental Environments for Children with Autism Spectrum Disorders
The first session speaker was Leah Stein Duker, assistant professor at the University of Southern California Chan Division of Occupational Science and Occupational Therapy. Presenting virtually, Stein Duker shared her work in creating sensory-adapted dental environments for children with autism spectrum disorders (ASD) that she used as a case example for an oral health value proposition. She described the pain points for children with ASD that can lead to overreactions to stimulation and can be exhibited as fight-or-flight reactions. The difficulties may be induced by auditory stimuli (caused by dental equipment or a crowded office), tactile stimuli (such as feeling on face and inside of the mouth by a dentist’s gloved hand and their equipment), olfactory stimuli (resulting from the taste and smell of the prophylactic paste, fluoride varnish, dentist gloves, and even the perfume of the provider), vestibular movement stimuli (from the feeling of reclining back in a chair), and visual stimuli (caused by bright lights in the clinic and the overall visually distracting environment). Stein Duker shared that these differences in sensory processing stimuli are so common in the ASD population that it was added to the DSM five diagnostic criteria for the condition.
To address the sensory overstimulation, Stein Duker developed an intervention with a multidisciplinary team targeting those sensory experiences during a preventive dental care visit. The resulting sensory-adapted dental environment tackled the various stimuli. To develop this intervention, a team, including people with backgrounds in occupational therapy, dentistry, and psychology, was assembled. The adapted environment modifies the visual, auditory, and tactile stimuli of the dental office. For instance, the overhead lighting was switched off, darkening curtains were placed over the windows, and the dentists used a headlamp to direct the light into the mouth, not the eyes. In addition to the soothing audio and visuals played in the room, a pediatric X-ray bib was used to provide extra weight, and a wrap gave the child tactile deep pressure sensations to provide a calming effect on the nervous system. To assess its effects, a randomized controlled trial was performed including 220 children with ASD between the ages of 6 and 12 years (Stein Duker et al., 2023). Each child had two visits for dental cleaning, one with and one without the environmental changes. Stein Duker found that the adapted environment resulted in significant improvements in physiological distress and behavioral distress, while it did not decrease the quality of care. Furthermore, she found there were no differences in cost-related variables, and it resulted in high satisfaction for caregivers and children.
Stein Duker recognized that her findings were part of a study but noted that it is feasible to implement these low-cost interventions in the real world as this method is highly scalable. Minimal training is required for its implementation, and the modifications do not require clinic renovations, with only a one-time cost. The method is now included in the American Academy of Pediatric Dentistry’s list of best practices for behavioral guidance as a potential technique to use with patients with anxiety or special health care needs (American Academy of Pediatric Dentistry, 2023).
During the audience question-and-answer period, Stein Duker was asked if this would also work for adults. Stein Duker said this has not yet been researched for autistic adults, but it is part of her plans to investigate. It has been pilot-tested with success for adults with intellectual and developmental disabilities. Another audience member inquired about the importance of training and whether staff training would be needed on top of the additional costs to the environmental changes? She replied that the process requires minimal training to implement, is easily portable, does not require renovations to the clinic, and it has only a one-time cost associated with it, which could easily be decreased from the $6,000 that she and her colleagues spent in conducting the study. A final audience question inquired what can be done for patients who are already traumatized from past experiences? Stein Duker responded that each individual is unique and would require tailored adaptations, but a good starting point would be to provide a graphic depiction before treatment of all the steps that will happen so the patient knows what to expect. Wolff then asked Stein Duker if her team had done anything related to home care with the caregivers to assist them in routine home care? Stein Duker said they did not, but plan to do that. Training parents would help for things like low-texture, low-taste toothpaste to reduce sensory issues, she noted, and would require using the shared expertise between occupational therapy and dentistry.
Onsite Mobile Oral Health for People with Disabilities
Betsy Lee White is chief operating officer at Access Dental Care, a mobile special care dentistry practice that serves people with disabilities and older adults in North Carolina. White discussed a 24-year effort that began as a pilot project. Her organization provides comprehensive, mobile dental care to individuals in skilled nursing homes, group homes for those with intellectual and developmental disabilities, Program of All-Inclusive Care for the Elderly (PACE) participants, and community-dwelling individuals that are behaviorally or medically complex. The project operates as a nonprofit organization, and has support from the North Carolina Dental Society and other locally interested groups. Its goal is to take the dental office to the community. To do this, a team made up of a dentist, dental hygienist, and two dental assistants—with support from social workers and a logistics coordinator—goes into the community 5 days a week. Seventy percent of the activities performed in the program are diagnostic and preventive services, 10 percent are oral surgeries and extractions, 12 percent are “drill and fill,” and 5 percent of the team’s work is related to dental partials, which are removable dental appliances used to replace missing teeth.
White then presented data collected by her and her team in 2023 on caries risk assessment as part of CareQuest Institute’s initiative on community oral health transformation. Their results showed that 72 percent of the patients they included were at high risk for dental caries. White emphasized the potential cost savings if the people in this study could receive preventive care more than a couple of times a year. “The reimbursement for that would add up to $652,” she noted, which would be significantly lower than the roughly $10,000 she estimated it would cost for sending the same person to the operating room for dental care.
Patients in the community with special health care needs face many barriers. The example she used was a patient with multiple sclerosis who was previously refused at a dental office because they were in a wheelchair. White said her team was able to treat this patient, but the paperwork may take months to go through the system. White underscored the need for a system that allows groups like hers to work with people who have intellectual or developmental disabilities or other special health care needs. “We know how to do this,” she said. “We just need a system that allows it.”
During the discussion, White received a question about compensation. Her response was that if they were reimbursed for all the services they provide, it would bring in an extra $2 million, which would help them grow. Wolff then asked where the funding for their work came from and whether it was based mostly on charitable donations or grants? White said they started the program with grants, but they work to make sure that their clinical operations are self-sustaining. This is becoming a bigger challenge, she remarked, as the reimbursement rate in North Carolina has gone down. “We are below the reimbursement rate that we [had] in 2008 and that equals 34 cents on the dollar.”
VESTED INTEREST GROUP INPUT ON A POTENTIAL VALUE PROPOSITION
Richard Berman introduced the next session saying, “To have an effective program or a new project that is sustainable and meaningful, the needs of the interested groups have to be recognized.” This constitutes the value to the groups. To explore an oral health value proposition, Berman described the two-part process through which three randomly assigned breakout groups first met to discuss an oral health value proposition before transitioning to a self-identified interest group in the second half of the allotted time. The three groups were (1) persons with disabilities, (2) educators and providers, and (3) payers and policy makers. Coleaders of the three groups presented discussions from their breakout group conversations on their interest group’s pains and gains that would make up an oral health value proposition for their target group.
Persons with Disabilities
The breakout group discussing the pains (Table 3-1) and gains (Table 3-2) for persons with disabilities was led by Teresa A. Marshall and Daniel W. McNeil. From the discussion, McNeil said, it became clear that the pains were related to access and ability to find professional dental care. Adequate care is difficult to find for this group, and there are often long waits to see a provider. Furthermore, access is also limited by hidden copays and difficulty in getting to dental care offices in terms of transportation and accessibility of the dental office and building.
TABLE 3-1
Oral Health Value Proposition Pains for Persons with Disabilities.
TABLE 3-2
Oral Health Value Proposition Gains for Persons with Disabilities.
A second pain point for persons with disabilities is the demand it adds to caregivers. Many caregivers are having issues with burnout stemming from the psychological demands of their responsibilities and their overwhelming concern for the health and welfare of their family members or the person with whom they are working. The third mentioned pain point was the view on the value of oral health care, or the prioritization of oral health. Persons with disabilities and their caregivers often have many competing priorities in life, including other health care problems, and there might be limited understanding of the importance of oral health for overall health.
The possible gains for persons with disabilities for oral health were also discussed. One gain that was noted was that taking care of oral health can lead to improved quality of life, better nutrition, and improved physical and systemic health. Another gain is that innovations in materials and technology result in an easier delivery of care and provide better access to care. An example of this is teledentistry, which can take away some of the pains in terms of accessibility of oral health care for persons with disabilities. Finally, another gain that was discussed for this interest group was the progress being made toward inclusion. Improvements in awareness, acknowledgment, and acceptance, as reflected in recent changes to National Institutes of Health policies, are important gains for persons with disabilities. McNeil commented that there is still work to be done, but positive signs of change are happening now.
In discussing what it would take to achieve the top three gains while minimizing the mentioned pains, the breakout group leads noted three important aspects (Figure 3-4). McNeil reported on conversations from his breakout group where educators were being called upon to train students to be competent providers for persons with disabilities, and this would include didactic and experiential training. Additionally, payment plans for this type of work would be very important. He also suggested that there is a social shift in students and dental educators, and that educators are behind students in terms of their focus on social justice. Lastly, McNeil reported the view discussed in his breakout group that persons with disabilities and caregivers be involved in education to better train dental students and residents. People with disabilities use the statement “For us, with us, by us,” to make sure they are included in decision making, education, and care to make things better for their group. To achieve this goal, said McNeil, it is important that there is collaboration of all professional groups, not just dental, but a broad array of medicine, behavioral, and social scientists as well, alongside persons with disabilities and caregivers who must be included as agents of change.
FIGURE 3-4
Oral health value proposition for persons with disabilities. SOURCE: Presentation by Marshall and McNeil, February 16, 2024.
Providers and Educators
The second breakout group discussed the value proposition model for interprofessional providers and educators. This breakout group was led by Jeffrey Stewart and Cynthia Lord. Lord explained that the group discussed several pain points for providers and listed three items as most important (Table 3-3a). One of these pain points is that providers are unable to change federal or state policies. There are no valid research data that a different model of providing oral health care in a medical setting would improve patient care, she said. This results in medical schools not being incentivized to teach oral health care. The second pain point discussed evolves around the siloed ways in which care is provided to patients. There is a need for more integration of dental care with medical care. Working together and understanding the benefits and patient needs are important for this, Lord noted. The third pain point involves issues with the system, including documentation, billing, and coding. Since these are conducted separately for medical and dental care, it increases the gap between the two, which led to a conversation about a need for integrated electronic health records for best patient outcomes, she said.
TABLE 3-3a
Oral Health Value Proposition Pains for Providers.
Lord then described the group’s discussion about educators. Educators have two pain points, she said (Table 3-3b). While there are the Interprofessional Education Collaborative competencies and accreditation standards that require interprofessional work, the breakout group talked about how interprofessional education has “a long way to go” in integrating faculty and processes in oral health. Schools are still very siloed in terms of medical and dental care education. To improve this, Lord commented, there is a need to start early in a student’s educational process. Interprofessional education exists, but it is not standardized and should be more highly valued, like basic science and clinical medicine. These factors are important to ensure practitioners work together and maintain a patient-centered approach, Lord said.
TABLE 3-3b
Oral Health Value Proposition Pains for Educators and Providers.
Lord said the gains for providers and educators include the potential use of electronic health records (Table 3-4). Integrating dental records with medical records would be essential to allow for effective communication between the siloes. Another gain is that students have the desire to learn from each other, and this can facilitate interprofessional collaboration. Lord said that students care a lot about being efficient and sharing information. There is excitement from learners who, as noted in the group discussions, want more interprofessional collaborative opportunities. Additionally, dental offices can serve as portals into the medical system, she said, by providing screening and identifying problems detected during routine dental exams. Lord then commented that accreditation standards are essential. The standards exist now and include interprofessional work, but more can be done using accreditation as a building block on which to expand.
TABLE 3-4
Oral Health Value Proposition Gains for Educators and Providers.
For educational gains, Lord called out the group’s emphasis on interprofessional education to effectively care for persons with special needs. This, she said, can align with the needs of educational institutions, especially when it improves the overall capabilities of the institution.
In describing what it will take to achieve the gains while minimizing the pains, Lord summarized the group’s conversation by saying it is important for dental professionals to interact with undergraduate students to help promote the field and relationships. Provider reimbursements are also key, she added, because without financing, there is no incentive for change. A collaborative spirit will go a long way to achieving interprofessional collaboration, which can be supported by minimizing competition among related specialties. Addressing scope-of-practice issues was also discussed by the group; it believed such issues require policy changes and input from other interest groups. More specifically, Lord said, professional associations can amplify what it takes to become a specialist, and policy makers can weigh in on the sorts of tests or procedures that can be run by oral versus medical health specialists. Lord added that if patients or persons with disabilities and their caretakers demand change, if they are convinced that oral health will improve their overall health, this group can work with providers and educators to push policy makers for what they feel is better care.
During the discussion, participants brought up additional pain points, including challenges to education integration caused by an already overloaded curriculum. Lord responded by saying that oral health is already included in topics in medical school as it is all connected; it does not require separate courses. Online participants also noted stress and burnout, particularly for students. Lord suggested that maybe there would be less of both if there was more interprofessional collaboration.
An oral health value proposition for educators and providers is presented in Figure 3-5.
FIGURE 3-5
Oral health value proposition for educators and providers. SOURCE: Presentation by Stewart and Lord, February 16, 2024.
Payers and Policy Makers
The third breakout group, led by Marko Vujicic and Donna M. Hallas, discussed the pains and gains (Tables 3-5 and 3-6) for a potential oral value proposition for the payers and policy makers interest group. Vujicic explained that the pain points discussed in the breakout group included existing payment models. First, current incentive structures are reinforcing disease treatment rather than rewarding health, and these structures are a major driver of provider behavior, he said. This is true for both the public insurance programs and the private insurance programs. Second, there is a lack of usable, actionable, and integrated data and information. This includes a lack of medical and dental health information in the same health record, patient-reported outcomes, and identifying patients with disabilities. In particular, data that are usable and actionable are missing. Third, clinical guidelines can facilitate policy changes, but there is currently a lack of prescriptive directives. For instance, if the system were to move toward one that promotes health wellness, focusing on prevention, is the science there to direct how to keep a patient free of caries, Vujicic asked. Not enough protocols might exist right now to answer this question.
TABLE 3-5
Oral Health Value Proposition Pains for Payers and Policy Makers.
TABLE 3-6
Oral Health Value Proposition Gains for Payers and Policy Makers.
Potential gains discussed by the interest group included cost savings. It is essential that a financial return on investment be provided for the enhancement of oral health, Vujicic said. This would not only include the health care cost savings, but also factors such as better employment and quality of life. Another possible gain is better care. Vujicic noted that this is a slow movement in the U.S. health care system. There is movement of the systems toward a focus on outcomes and better quality of care. The final gain his group discussed was a commitment to solutions related to equity, and the recognition of equity as a priority within U.S. health care policy. This is particularly true within public insurance programs, Vujicic added. Like the other interest group reports, his group felt that to achieve these gains, while reducing the pains, collaboration with all other interest groups would be essential (Figure 3-6).
FIGURE 3-6
Oral health value proposition for payers and policy makers. SOURCE: Presentation by Vujicic and Hallas, February 16, 2024.
- Understanding the Value Proposition in Oral Health - Whole-Person Oral Health Ed...Understanding the Value Proposition in Oral Health - Whole-Person Oral Health Education
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