Closing the Gap: Coordination of Care Between Physicians and Dentists
Robert Lewando, DDS, MBA; and Edward Murphy
Many dental healthcare providers have found that encouraging patients to return for their recall visit to be increasingly difficult, despite increased awareness of the importance of oral health in the management of chronic diseases.
Diabetes mellitus, which affects 9.3% of the US population, and heart disease, causing 1 in 4 deaths, are among the chronic conditions demonstrated to have improved outcomes in overall health when simple preventive and periodontal treatments were rendered. People with diabetes have a higher risk for periodontal disease. In turn, the presence of periodontal disease may make it more difficult for people with diabetes to manage blood glucose levels, putting them at risk for diabetic complications. In heart disease, the bacteria found in periodontal disease, including Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythensis, and Treponima denticola, have been associated with atherosclerosis. Yet, patients with these health issues do not always obtain the well-rounded coordinated care they need.
In the past 2 years, Hawaii Medical Services Association (HMSA), a healthcare plan that offers both medical and dental plans, observed patients with coverage under both were not consistently receiving the recommended preventive or periodontal care, leading to less-than-optimal healthcare results. This situation was exacerbated because the primary-care physician did not always know whether the recommended follow-up dental treatment was being delivered in a timely manner. In other words, information about the medical and dental care needed for the patient were siloed within disparate delivery systems.
To help address the need for more readily accessible information on each patient, a software development company Applied Research Works developed a web-based application called Cozeva®. Initially, this program was made available to all primary-care medical providers rendering care to patients with HMSA plans, and automatically identified gaps in the member’s medical care to the provider.
Cozeva has been available to HMSA’s medical providers since 2012. This application helps physicians provide patients with more timely and appropriate care. Upgrades to this system occur regularly, and the 800 physicians associated with HMSA participating in this program receive a portion of their compensation based on how well any gaps in care are closed. However, the patients or caregivers are ultimately responsible for filling any voids in care, as they must make the necessary appointments and follow-up on recommended treatment. Despite this, patients often need to hear the same message reinforced by various providers, both medical and dental, before they are motivated to change.
Patients with both medical and dental coverage with HMSA can be encouraged by the dentists to close any medical gaps, while physicians can encourage members with dental coverage with HMSA to obtain any overdue dental care. The fact that the member will be seeing both the physician and dentist enables the same message to be reinforced from each clinician to help motivate that person to make appointments for the proper follow-up care.
As an additional breakthrough in the integration of the overall care model, HSMA launched Connected CareSM: Powered by Cozeva® to provide dentists with the same tools available to physicians to access the complete medical history of their patients. This creates the opportunity for the physician and dentist to work collaboratively for patients with both medical and dental coverage so that patients can be motivated and encouraged to receive all necessary treatment to improve overall health. Connected Care was introduced to dentists in 2016, with the intention to provide general dentists real-time access by early 2017. To date, approximately 200 dentists have been registered on Connected Care with an expectation that 800 will be involved by mid 2017.
This means Connected Care will give dentists access to the current and complete healthcare history for each patient, including prescription and laboratory information. Dentists will also be able to interact with their medical colleagues as an integral part of a real-time healthcare ecosystem. This is essential for when dentists are deciding crucial issues such as scheduling a shorter appointment because of the patient’s extensive health history. It may also provide much-needed clarification about laboratory results, current prescription usage, or the requirement for premedication based on the member’s health history. The potential time saved and the quality of the treatment able to be rendered by having this information readily available is invaluable. In turn, the physician using Connected Care will see gaps in dental care in addition to the voids in medical care they observe when using Cozeva. This program is in its early stages of implementation, but the potential to harness both physicians and dentists with a consistent message to the patient has great potential to change patient behavior.
The preventive dental-care gap identifies patients who have both medical and dental coverage through HMSA, are generally healthy, and have not seen their dentists in the past year for preventive and diagnostic services. This indicator alerts the physician that the patient is overdue for a dental check-up. Similarly, when the patient is at the dentist’s office, the dentist has access to the medical-care gaps and is in the position to encourage the patient to make a follow-up appointment with a physician.
The Connected Care screen also includes an indicator to alert the user when a member with either diabetes or heart disease has not seen the dentist in the previous 12 months. This signals both the physician and dentist that the member participates in HMSA’s Oral Health for Total HealthSM program, in which a member with one of these conditions receives additional preventive and periodontal services, as oral care is particularly important in helping to manage disease progressions. These extra dental services do not require a copay, coinsurance, or deductible, and are outside the patient’s annual dental benefit maximum. HMSA considers these additional dental services as integral to patients’ medical benefits and is not penalizing the patient in recommending care that is important in managing the medical condition.
This technology is a benefit for the physician, dentist, and patient. The physician has another tool to better manage a risk factor in the patient’s health, and the dentist becomes a partner with the physician in encouraging the patient to follow-up on any outstanding medical care. This is the first real-world model in which both physicians and dentists in private practice have the ability to communicate and work as a team in a patient-centered environment. The additional dental benefits offered to members with specific chronic diseases allows the dentist to provide treatment based on risk and not plan design alone. The rationale is that everyone needs dental care, but some need additional dental care to manage their medical health.
Although these dental metrics are a new addition to the system platform, it is an important milestone for physician-dentist collaboration to improve the overall health of patients. This relationship has generally not been fostered well in either dental-school or our professional collaborations up to now. The learning curve may be steep; however, the end result will be a healthier and more compliant patient and dentistry will have a seat at the table, contributing to the overall well-being of the patient.
About the Authors
Robert Lewando, DDS, MBA
National Clinical Operations
Life and Specialty Ventures
Life and Specialty Ventures Dental Management