Traditional Medicaid for Dental Care Is Broken. But A New Model Shows Promise.
Advantage Dental in Oregon shows us that high quality Medicaid oral health care is within reach — for less than what states are paying now.
A new dental care model, pioneered by Advantage Dental, provides high quality oral care to Medicaid recipients at 21 percent less than the national average by focusing on prevention. How does it work and can other states follow?
On July 1, Illinois will begin to cover oral care prevention services for adult Medicaid recipients. All covered adults will be able to receive periodic exams and cleanings performed by a dentist enrolled in the program.
Dental care is often overlooked in state-funded medical coverage, but oral issues can lead to a range of health problems, including increased risk of cancer, heart disease, stroke, preterm delivery and weight-related issues. Given this broader impact, new approaches to improve Medicaid will be most successful if they also address the oral health system.
In fact, “the population eligible for Medicaid is much more likely to need dental care and much less likely to be able to afford it,” The New York Times reported earlier this year. Policies and programs aimed at improving the financial and health impact of these diseases on Medicaid must address oral health an essential component.
For example, some states like Alabama are considering adding minimum work requirements for residents to be eligible for Medicaid. However, 35% of low-income Alabama residents cite oral health as an obstacle to job interviews. By offering adequate oral health care, states can support unemployed residents to get hired, making these types of requirements more attainable.
A new dental care model, pioneered by Advantage Dental in Oregon, is making it clear that it’s time to change this way of thinking. Public investment in oral care can have outsized returns in both cost and results.
A Better Model
By focusing on prevention, Advantage Dental provides high quality oral care to Medicaid recipients at 21 percent less than the national Medicaid average cost, according to DentaQuest’s original research.
In 2012, Oregon pioneered a new model of Medicaid care delivery that focused on integrating physical, dental and mental health services.
Its goal was to keep people healthy instead of just treating them when they were sick, by including oral and mental health care as a core part of the program and not an afterthought. Advantage Dental was one of the dental care organizations that participated in the program.
DentaQuest Institute studied Advantage Dental patients from 2011 to 2016 and compared these results to a national sample of Medicaid dental patients between 2013 to 2015, to see if the new approach had any effect on Medicaid’s quality of care or cost. The results were eye-opening.
"Advantage Dental has created a highly unique person-centered model that emphasizes prevention at every stage of life," said Dr. Natalia Chalmers, lead author of the study.
"Advantage's approach improved access, while [reducing] the need for more invasive treatments and lowered the cost of keeping their patients healthy throughout their lifespan."
How did Advantage Dental accomplish this and can Illinois, Alabama and other states adopt this approach for similar outcomes?
Start Preventive Care Early
In Advantage Dental, better oral health begins before we are born.
Pregnant women in the program were assigned a primary care dentist as part of their prenatal care. These women were more likely to receive dental care and their children were more likely to be caries-free by the age of 2, compared to pregnant women who were not assigned or educated within the program.
Children also received more preventive care overall.
Twenty percent of children enrolled with Advantage Dental had a caries risk assessment, from which providers created individually tailored risk-based visit and prevention plans. In contrast, almost no children received a risk assessment in the national Medicaid sample group.
As part of those prevention plans, about a third of children in the program under the age of 14 received sealant placements.
Combined with chronic disease management, these preventive actions for young patients reduced the need for restorative and surgical services by 6 percent from the national average, in just 5 years.
It’s notable that during this time period, 18,000 more children under age 20 joined Advantage Dental. The program absorbed the new patients while maintaining the same quality of care.
Meanwhile, Medicaid’s sample size held constant in both care and patient size during the duration of the study.
Invest in Thoughtful Care Over Time
Even as adult enrollment in the program increased — by well over 50 percent — adult Advantage patients were also 6-7 percent less likely to need restorative dental services than their national cohort.
One way Advantage was able to keep up with this increase in patient volume was by proactively rolling out new and more effective preventive care treatments.
For example, new mothers were instructed to chew xylitol gum to help prevent transfer of the bacteria that causes dental decay, increasing the overall oral health of both mothers and their babies.
It also used technology to make treatment more efficient.
Advantage patients had access to a 24/7 emergency hotline for pain management and expedited appointments. This reduced visits to the ER outside of dental office hours and provided patients more comprehensive relief than a trip to a general urgent care center could provide.
Using the state health information exchange, Advantage could identify patients who presented at the ER for oral health issues that could be better supported in a dental setting. The data enabled Advantage to follow up with these patients immediately after hospital discharge in order to further address those dental needs.
Redefine the Traditional Care Setting
This model doesn’t work in a vacuum. Since its inception, the model was designed to provide care for as many patients as possible by redefining the traditional care setting.
During the study period, Advantage sent 15 full-time dental hygienists to community-centric locations like schools, Head Start programs, and the Special Supplemental Nutrition Program for Women Infants and Children (WIC) to reach community members who might not otherwise have access to oral health care.
It worked. These hygienists were responsible for 16 percent of all preventive services performed for children ages 20 and under and 10 percent of these services overall.
Provide Cost-Effective Treatment
During the course of the five-year study period, Advantage was able to provide better care for an increasing Medicaid population while also reducing the overall cost of oral care for both adults and children.
The difference in estimated costs are particularly stark for adult patients -- To treat 1,000 adults in 2015, Advantage spent $111,206, with restorative services accounting for 51 percent of that total cost.
For the same 1,000 adults in the national Medicaid sample, the program spent $141,547 -- 21 percent more overall -- and 40 percent more on restorative care.
Built for Scale
These kinds of results aren’t accidental. Advantage Dental was paid by the State of Oregon based on the quality of services it provided to Medicaid patients. Providers were incentivized to invest in early and ongoing preventive care and approach their care creatively.
"The data revealed that when an accountable care model includes oral health and is supported by the state Medicaid agency, it can do just that — improve outcomes and lower overall dental costs,” explained Tequila Terry, executive director of the DentaQuest Institute.
According to Terry, the ethos behind this improvement is not unique to Oregon.
“This is a person-centered, disease management approach. Any state in the U.S. is capable of moving away from the ‘drill and fill’ paradigm to one that proactively addresses oral health at a lower cost, with high quality, and with better outcomes.”
Ultimately, Oregon’s example proves this model of care is possible.
To learn more about whether a prevention-based model is a fit for your state, read the full white paper on Advantage Dental’s Approach for better health, better access, and better value and contact us directly for more information.