As patients continue to put off dental care during the COVID-19 pandemic, some health systems are rolling it into their medical appointments in hopes of getting more teeth checked and cavities filled.
The movement toward medical-dental integration is hardly new, but providers on both sides said it's gained particular importance at a time when people continue to put off care amid the most recent COVID-19 wave. Dental care was the most skipped type of care in a new Robert Wood Johnson Foundation survey that found 11% of adults had delayed or forgone care in the past 30 days over coronavirus concerns.
"It's excitingly more normalized than it was even five years ago," said Jane Grover, director of the American Dental Association's Council on Advocacy for Access and Prevention. "COVID has kind of brought this to light."
Marshfield Clinic in Wisconsin, for example, has long had an integrated medical and dental electronic health records system wherein medical and dental providers can communicate and refer patients to one another.
Not only that, Marshfield Clinic's medical providers routinely ask patients whether they see a dentist and when their last dental appointment was. For their part, dental providers check blood pressure and screen for prediabetes, said Tena Springer, dental division administrator for Family Health Center of Marshfield, a federally qualified health center affiliated with Marshfield Clinic. The pandemic has made providers especially diligent around that.
"I think it was an opportunity to really tune up our systems to make sure we communicate effectively on that so patients didn't fall through the cracks," Springer said.
At the highest level, medical-dental integration can look like dental hygienists popping into primary care visits and checking out patients' teeth, even adding sealants. But providers say that's still relatively rare.
Overall, medical-dental integration is happening in somewhat isolated pockets across the country at various health systems, insurers, universities and federally funded health clinics. The CDC in late 2020 picked a group called the National Association of Chronic Disease Directors to put together a national framework around medical-dental integration with recommendations and strategies for providers.
So far, NACDD has reviewed more than 700 scientific articles on medical-dental integration. The group plans to convene an in-person meeting in March to discuss creating the national framework, said Barbara Park, a public health consultant for NACDD who specializes in oral health.
Park said COVID-19 made the work especially poignant.
"When people get back into care, maximizing time with that provider to assess a number of issues they have going on is very important," she said.
At MetroHealth in Cleveland, dental clinics are embedded within the broader health system and dentists treat patients in hospital settings, said Gregory Heintschel, a dentist and the system's chair of dental medicine.
"We're working alongside our physician colleagues every day, all day long," he said.
It helps that both the medical and dental providers are MetroHealth employees and have access to the same Epic electronic medical records platform. That setup encourages cross-referral between specialties, Heintschel said.
MetroHealth's integrated model even extends into operating rooms. Oftentimes when patients with developmental disabilities have dental procedures scheduled that require anesthesia, medical providers schedule services within the same visit, such as a female patient that needs a gynecologic procedure.
In cases like that, though, MetroHealth has to get the OK for coverage from medical insurers for the dental procedure, even though dental insurers don't require prior-authorization, Heintschel said. That's where it gets challenging.
"That is a huge problem right now, honestly," he said. "It's becoming more problematic, more chaotic."
Some research suggests medical-dental integration can boost a health system's bottom line. Adding dental care to primary care settings impacts a practice's annual net revenue by an estimated -$92,000 in the first year due to startup costs and almost $105,000 in subsequent years, according to a 2020 study by a team of Harvard University researchers.
More than 40 state Medicaid programs pay medical providers to address children's oral health in some form or another.
For example, most states cover topic varnish, a fluoride gel that takes seconds to apply to children's teeth. In Nevada, an office that applied the varnish for 20 eligible children per week would increase its revenue by an estimated $55,432. In Washington, that same service and frequency would add $73,102 in annual revenue because the state pays separately for the varnish application, oral exam and oral health risk assessment.
HealthPartners, a not-for-profit system in the Minneapolis area, operates 23 dental clinics in the same buildings as medical providers. Like other systems, HealthPartners' Epic platform integrates patients' medical and dental records, allowing the two sides to communicate and refer patients.
While it's uncommon for HealthPartners' dental providers to pop into medical visits, that could happen in the future, said Todd Thierer, associate dental director for primary care for HealthPartners Dental Clinics.
Right now, HealthPartners is focused on projects like having dental providers ask kids about getting their commonly missed second dose of the human papillomavirus vaccine. The system is also working on training caregivers to apply fluoride varnish for dementia patients who can't visit dentists, Thierer said.
"That's one of the beauties of being an integrated system like HealthPartners, because there is kind of this synergy around these projects," he said. "We're able to work on them and integrate them much easier than a non-integrated system can."