AN INCREASING number of studies are linking oral health to general health. While not establishing a direct cause-and-effect, the reports show that early prevention and treatment of gum disease could improve outcomes for pregnancy, heart disease and diabetes.
Dental benefits have long been the stepchild of healthcare coverage, but as oral health makes an important case for improving overall health, insurers are putting more teeth into preventive oral care programs to stave off future, more complex conditions, such as preterm deliveries, off-the-chart blood sugar levels and preventable heart disease. The Centers for Disease Control and Prevention estimates that 80% of adults will have some form of periodontal disease.
BlueCross BlueShield of Tennessee recently released a study, "Healthy Mouth, Healthy Body," that confirms that link. Members of the insurer who had received diagnostic or preventive care from their dentists had 2% lower healthcare costs—potentially saving $5.5 million annually; 16% fewer inpatient admissions; fewer incidences of coronary artery disease, congestive heart failure, diabetes and hypertension; and 12% lower imaging costs compared with those who did not visit their dentists.
In addition, the preventive group realized 4% lower per-member-per-month (PMPM) healthcare costs than members with evidence of periodontal treatment when costs for all dental services were removed. Finally, the preventive group also indicated less use of certain medications—hepatitis C agents, calcium channel blockers and inflammatory bowel agents, among others—than those in the periodontal group or those not receiving any dental services.
By using dental and medical claims from fully insured members, the BlueCross BlueShield plan developed an oral health program integrating education, awareness, case management and use of a coupon to fund an additional annual dental cleaning.
Hartford, Conn.-based Aetna and Columbia University College of Dental Medicine conducted a study of 145,000 Aetna members with dental and medical coverage over two years, and found that periodontal care appears to have a positive effect on the cost of medical care, with earlier treatment resulting in lower overall medical costs for members with diabetes (9%), coronary artery disease (16%) and stroke (11%).
Using 2003 claims data, Dental Blue, Blue Cross Blue Shield of Massachusetts' dental plan, examined the medical costs of members diagnosed with either diabetes or coronary artery disease (CAD). For patients with these diagnoses, the health insurer categorized each member into either a compliant group that had received a dental prophylaxis or periodontal treatment in the prior 12 months, or into a non-compliant group that had not received this dental care.
Within the diabetes group, Dental Blue found that compliant members had $146 PMPM lower medical costs than members without treatment. The CAD group members who received dental prophylaxis and/or non-surgical periodontal treatment had $238 PMPM lower medical costs than members who did not seek these treatments.
"We believe that some of the differences in the two groups' costs are related to a behavioral component," says Joseph Errante, vice president, Dental Blue in Boston. "Members who receive appropriate dental care are more likely to be compliant with their healthcare providers' prevention and care recommendations than members who did not receive appropriate dental care."
To address this discrepancy, Dental Blue has developed an education awareness program targeting members with diabetes who had not received dental care. After a year of outreach in 2006, there was a 32% increase in compliance, growing to 38% in 2007. The program has been extended to members with coronary artery disease, while pregnant women receive education at their OB/GYN offices.
"We have created real value by offering up to four cleanings a year at no cost to members and without an effect on deductibles or maximums," Errante says. "We are also exploring the link between antidepressants and tooth decay and oral health and pneumonia, especially in the long-term care environment."
Jeff Album, director of public affairs for San Francisco-based Delta Dental of California, New York, Pennsylvania and affiliates, considers the integration of medical/dental an evolution, not a revolution, progressing slowly from education for patients and providers to targeted care management. Lying along the continuum are dental wellness programs incorporating incentives for preventive measures and highlighting the oral/overall health link with focused educational materials for members who are at risk.
"We are looking at the science of treatment for oral disease," says Sheila Strock, dental policy officer, Delta Dental. "We are conducting ongoing research of areas of medicine as they relate to dental disease and identifying key populations at risk. Then we can develop a plan policy in alignment with evidence-based medicine."
As proof, Delta Dental covers one additional cleaning or oral evaluation yearly with a copayment, in addition to the usual two times for its members who are pregnant. The enhanced benefit is at no additional cost to an employer group. Strock says that Delta can work with medical carriers to drive a model for at-risk patients, such as those with diabetes or pregnant women, and to drive access to care.
UnitedHealthcare Specialty Benefits in Golden Valley, Minn., is another MCO that has made the connection between oral health and disease and is studying medical PMPM expenditures for those with dental care versus those without.
Dennis Spain, DDS, chief dental officer for UnitedHealthcare Specialty Benefits, says that it is not always easy to convince stakeholders of the relationship between oral health and certain diseases and to acknowledge that preventive care necessitates behavior change. United's key strategy is to make its members, employer groups and providers more aware of the connection.
Starting last year, United modified its benefits for pregnant members by waiving coinsurance and maximums to ensure they receive necessary periodontal care. Spain estimates that the insurer spends $50,000 more for each preterm delivery and that as many as 12% of births are pre-term.
"If you can reduce incidents by half, you may be looking at a 17-to-1 return on investment," he says.
Mari Edlin is a frequent contributor to MANAGED HEALTHCARE EXECUTIVE. She is based in Sonoma, Calif.
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