Oral health, primary care must unite to achieve health equity

Though most recognize oral health as part of overall well-being, dental care remains out of reach for a large segment of the U.S. population, according to a report released on March 31 by the Primary Care Collaborative (PCC).

Leveling the playing field hinges on the integration of oral health and primary care by increasing oral health coverage through government programs, supporting a more equitably distributed oral health workforce, reforming payment models, and more, the organization noted in the report, titled "Innovations in Oral Health and Primary Care Integration."

"It is imperative that we work toward a more equitable and accessible system of care, one in which oral health is not an afterthought, but a pillar in achieving health for all," the authors wrote.

Care for all

Approximately one-third of individuals in the U.S. do not have dental coverage, and those with a low income who receive public insurance have significantly lower rates of dental access than those with more money. Comprehensive care models can enhance population health and address health inequities. The COVID-19 pandemic exposed the failures of the current healthcare system for marginalized communities, including people of color, the homeless, and those with disabilities.

"Comprehensive primary care services can begin to rectify the systemic injustice that continues to disproportionately impact the health of these populations by ensuring that patient needs are met in a personalized, holistic manner that is identity-affirming and addresses social needs, prevention, education, and health needs without fragmentation," the authors wrote.

Health justice may be achieved if primary care and oral health communities advocate for policy changes, according to the PCC, which includes a diverse group of stakeholders from the public and private sectors in the U.S.

They should ask policymakers for the following:

• Make dental coverage a component of health insurance instead of an optional benefit by expanding Medicaid and adult Medicaid dental coverage and adding a dental benefit to Medicare.
• Expand access to dental care by calling on education leaders to support a more diverse, equitably distributed oral health workforce to better meet the needs of communities across the U.S.
• Create equity-driven policies that compel or incentivize clinicians to accept all types of coverage, such as Medicaid.
• Address health-related social needs, such as food insecurity and a lack of transportation, by integrating them into primary care and oral service delivery.
• Enact universal health coverage in the U.S. to achieve lasting health justice.

"We must continually ally with and defer to the voices of patients and their communities to ensure that the systems we build are respectful, compassionate, and just," the authors wrote.

Time for payment reform

Another primary strategy for integrating oral health and primary care and eliminating disparities would be to develop new payment models that support reimbursement structures that incentivize prevention, effective chronic care management, and whole-person care.

The conventional fee-for-service reimbursement structure that is almost universal for oral health has hindered its ability to be included in comprehensive reimbursement models, such as global payment, that physician-led accountable care organizations use. Comprehensive reimbursement models allow independent and organization-based medical practices to build diverse teams that can deliver complete, patient-centered services.

However, the fee-for-service system incentivizes maximally invasive procedures that call for billing at the highest rates and provides little or no reimbursement for services, including patient counseling and preventive oral care delivery. Also, a lack of robust diagnostic codes and quality measures stymies oral health integration into independent primary care practices and accountable care organizations, the authors wrote.

Therefore, the use of dental diagnostic codes should be mandated, and dentistry should work with public and private stakeholders to move toward a value-based system and away from fee-for-service reimbursement, according to the report.

Adopting delivery and payment models that optimize health cannot be achieved without enhanced transfer and sharing of dental and medical health records. These data can be leveraged to get a better understanding of medical and oral health inequities and associations.

"When such systems are commonplace, evidence-based, integrated oral health care will be much easier to achieve," they wrote.

Achievable but challenging

Change will not be easy. Adopting new policies will require a shakeup of long-standing care systems, as well as the development of new ones, and those are not simple tasks, the authors acknowledged. But the effort comes with a big payoff.

"More integrated and enriched models of primary care and oral health delivery will empower clinicians to work together to provide the care their patients need and to develop models of support and outreach to meet those patients where they are," they concluded.