Glassman OHFlorida EvolvingOralHealthIndustry · 11/1/2019 2 Virtual Dental Home Consulting Public Health Care Spending vs Debt ... Teledentistry Dentist to dentist interactions:

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Virtual Dental Home Consulting

Paul Glassman DDS, MA, MBAAssistant Dean for ResearchSchool of Dental MedicineCalifornia Northstate [email protected]


Disclosures

The presenter has consulting arrangements with the following entities:

• DentaQuest Impact, Inc.

• The Colgate‐Palmolive Company

• Virtual Dental Care

• Idaho Department of Health

• Rhode Island Department of Health

• Multiple dental care providers


Health Care Systems

• Increasing focus on health vs health care

• No longer enough to provide late stage repair

– We need to intervene in the “social determinants of health”

• The population is changing

– Older, more diverse, more complex

• Increasing interest in community as the level of focus

• Increased use of “big data”, value, and collaboration


Drivers of the Quality Movementin the U.S. Health Care System

1. the skyrocketing cost of health care unrelated to improvement in health outcomes,

2. increasing understanding of the harm and unwarranted variability our fragmented health care system produces,

3. evidence of the profound health disparities that still exist in the population in spite of scientific advances in care, and

4. increasing awareness of these problems in the age of consumer empowerment.


Drivers of the Quality Movement#1 – The Cost of Health Care


Health Care Spending 1980‐2013

http://www.commonwealthfund.org/publications/issue‐briefs/2015/oct/us‐health‐care‐from‐a‐global‐perspective. Data: OECD Health Data 2015.

Percent of GDP

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Public Health Care Spending vs Debt


Health Care Spending

“Medical costs are the tapeworm of American economic competitiveness”

New York Times. May 6, 2017

New York Times: Warren Buffett, at Berkshire Meeting, Condemns Republican Health Care Bill. 5/6/17. https://www.nytimes.com/2017/05/06/business/dealbook/warren‐buffett‐berkshire‐health‐care.html?action=click&contentCollection=Europe&module=Trending&version=Full&region=Marginalia&pgtype=article


National Oral Health Expenses

Source: CMS National Health Expenditure NHE Historical and projections, http://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Statistics‐Trends‐and‐Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.htmlhttp://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Statistics‐Trends‐and‐Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html

0%

50%

100%

150%

200%

250%

300%

350%

$0

$50

$100

$150

$200

$250

U.S. National Dental Expenditures 2000 ‐ 2025 ($ Billions)

Dental Services (DS)

DS % of 2000 Level (321%)


Health Spending by Condition

General Health: MEPS: Expenditures by Medical Condition 2013, Table 3http://meps.ahrq.gov/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2013&Table=HCFY2013%5FCNDXP%5FC&_Debug=Dental Health: MEPS: Expenditures per Person by Health Care Service 2012, Table 3http://meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2013&Table=HCFY2013%5FPLEXP%5FB&VAR1=AGE&VAR2=SEX&VAR3=RACETH5C&VAR4=INSURCOV&VAR5=POVCAT13&VAR6=REGION&VAR7=HEALTH&VARO1=4+17+44+64&VARO2=1&VARO3=1&VARO4=1&VARO5=1&VARO6=1&VARO7=1&_Debug=

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

$110,000(M

illions)

Medical Expenditure Panel Survey ‐ Top 25, 2013


Oral Health Expenses

Source: Bureau of Labor Statistics: Consumer Price Indexhttp://www.bls.gov/cpi/cpi_dr.htm

100%

120%

140%

160%

180%

200%

220%

240%

260%

280%

300%

Consumer Price Index (CPI) and CPI for Dental Services (% of 1990 dollars)

CPI % of 1990 Level (177%)

CPI‐DS % of 1990 Level (285%)


Out‐of‐Pocket Health Expenses

In‐patient care (8.8%)

Outpatient/ emergency room care (6.4%)

Physicians'services (15.9%)

Dental services$30.7 billion (22.2.0%)Other professional

services (8.1%)

Prescriptiondrugs (31.0%)

Medical supplies (7.6%)

Out‐of‐pocket health care total$138.5 billion

Source: Bureau of Labor Statistics. Consumer out‐of‐pocket health care expenditures in 2008. http://www.bls.gov/opub/ted/2010/ted_20100325.htm

Consumer out‐of‐pocket health care expenditures in 2008

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Virtual Dental Home Consulting Virtual Dental Home Consulting

http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIgraphic_1117_2.pdf?la=en


Dental Care Utilization in US

Age Group Total Population % Utilization Utilizers

2‐18 69,916,504 48.5% 33,909,504

20‐64 195,794,862 36.0% 70,486,150

65+ 47,760,852 43.7% 20,871,492

Total Utilizers 313,472,218 40.0% 125,267,147

Total Non‐Utilizers 60.0% 188,205,071

Most non‐utilizers are low income and havesignificantly more disease than utilizers!

Population Data: US Fact Finder: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk


https://www.cdc.gov/nchs/data/databriefs/db307.pdf


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The future of dental practice: DemographicsApril 10, 2015 By Eric Solomon, DDS, MA

Solomon S. The future of dental practice: Demographics. April 15, 2015. http://www.dentaleconomics.com/articles/print/volume‐105/issue‐4/macroeconomics/the‐future‐of‐dental‐practice‐demographics‐patients‐professionals‐and‐procedures.html



Disruptive Innovation


National Geographic Magazine, 1958

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U.S. Automobiles 1960s ‐> Luxury,

Cadillac

Buick

Pontiac

Sophistication


Japanese Automobiles 1960s ‐>Basic Transportation

Toyota



• Disruptive innovation, describes a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.



• Companies tend to innovate faster than their customers’ needs evolve

• Their products or services become too sophisticated, too expensive, and too complicated for many customers in their market.

• Historically the greatest profitability has been achieved by charging the highest prices to their most demanding and sophisticated customers at the top of the market.



• However, by doing so, companies unwittingly open the door to “disruptive innovations” at the bottom of the market.

• An innovation that is disruptive allows a whole new population of consumers at the bottom of a market access to a product or service that was historically only accessible to consumers with a lot of money or a lot of skill.


The Oral Health Industry

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The Oral Health Industry



‐50%

0%

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100%

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200%

250%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Percent Growth in # of Dental Establishments by # of Employees

0‐4

5‐9

10‐19

20‐99

100‐499

500+

Source: US Census: Statistics of US Businesses (SUSB). http://www.census.gov/programs‐surveys/susb/data/tables.html


The Quadruple Aim


The Era of Accountability


DeliverySystems

Measurement and Payment

Systems

Preventionand Behavior

Science

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Measurement and Payment

Systems


Measurement

• DQA

• Payers

– Dental Benefit Companies

– Public Payers

• Group Practices

• HRSA: Health Center system



Support Science


Qvist V, BorumMK, Moller KD, et. al. Sealing Occlusal Dentin Caries in Permanent Molars: 7‐Year Results of a RandomizedControlled Trial. JDR Clinical & Translational Research. January 2017:2(1):73‐86

ConclusionWe conclude it is possible to postpone restorative intervention of occlusal dentin caries lesions in young permanent teeth by non‐invasive sealing and thereby improve tooth longevity. Although all lesions required restorative treatment at baseline, more than half of the sealed lesions still did not require restoration after 7 years.


Qvist V, BorumMK, Moller KD, et. al. Sealing Occlusal Dentin Caries in Permanent Molars: 7‐Year Results of a RandomizedControlled Trial. JDR Clinical & Translational Research. January 2017:2(1):73‐86


Incomplete Caries Removal

• This 10‐year study evaluated bonded and sealed composite restorations placed directly over frank cavitated lesions extending into dentin vs. sealed conservative amalgam restorations and conventional unsealed amalgam restorations.

• The results indicate that both types of sealed restorations exhibited superior clinical performance and longevity compared with unsealed amalgam restorations.

• Also, the bonded and sealed composite restorations placed over the frank cavitated lesions arrested the clinical progress of these lesions for 10 years.

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• Increasing numbers of clinical trials have demonstrated the benefits of incomplete caries removal, in particular in the treatment of deep caries.

• Teeth treated with incomplete caries removal showed risk reduction for both pulpal exposure and pulpal symptoms.



• Teeth treated with incomplete caries removal had half to two‐thirds fewer pulp exposures compared to teeth treated with complete caries removal

• Partial caries removal and sealing into the tooth leads to the systematic and progressive arrest of the carious lesion.

Operative caries management in adults and children (Review)Ricketts D, Lamont T, Innes NPT, Kidd E, Clarkson JEThe Cochrane Library. 2013, Issue 3


Interim Therapeutic Restoration (ITR)

AAPD Policy on Interim Therapeutic Restorations (ITR)


The Declining Role for the Dental Drill


Fluoride VarnishSilver Diamine

Fluoride

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Sealing Caries


Care for Chronic Oral Diseases

Acute Care/Surgical

Intervention

Chronic Disease

Management


Total Health: How Long and How Well We Live

McGinnis JM & Foege WH. Actual Causes of Death in the United States. JAMA 1993; 270(18):2207-12 (Nov 10). McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93 (Mar).

Behaviors(alcohol, tobacco,diet, exercise,preventive dentalprocedures?)

40%10%

20%

30%

Genetics

Environment,Public Health

Health Care Delivery(procedures)


DeliverySystems


DeliverySystems

CommunityDeployment

Partnershipsand

Integration

Payment Systems

Workforce


Workforce• Allied dental personnel

– Community dental health coordinator

– Expanded function dental assistants

– Public/expanded function health dental hygienists

– Dental therapists

• Non‐dental personnel/interprofessional integration

– Community‐health workers

– General health professionals – physicians, nurses, etc.

– Social service professionals

– Educational system personnel – family advocates, teachers, etc.

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What is Telehealth?

http://cchpca.org/what‐is‐telehealth


Telehealth Modalities

• Live Video (synchronous)

• Store‐And‐Forward (asynchronous)

• Remote Patient Monitoring

• Mobile Health (mHealth)

What is Telehealth?


Teledentistry

Dentist to dentist interactions: share records, patients

Real time video surgical support

Real time video consultation – dentist to dentist/patient

Store‐and‐forward record review

Patient to dentist interactions

mHealth data collection

Telehealth‐connected team delivery systems


mHealth


mHealth

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http://www.businessinsider.com/dentists‐in‐china‐used‐a‐robot‐to‐perform‐implant‐surgery‐2017‐9


The ADA House of Delegates passed Resolution 45H‐2015, Comprehensive ADA Policy Statement on Teledentistry, in November at ADA 2015 – America’s Dental Meeting.


Center for Connected Health Policy. State Telehealth Laws. Fall 2019. https://www.cchpca.org/sites/default/files/2019‐10/50%20State%20Telehalth%20Laws%20and%20Reibmursement%20Policies%20Report%20Fall%202019%20FINAL.pdf


National Conference of State Legislatures (NCSL). Increasng Access to Health Care Through Telehealth. May 2019. http://www.ncsl.org/Portals/1/Documents/Health/Healthcare‐Access_Telehealth_v03_web.pdf


2019 Telehealth Reports: Highlights• 50 states + Washington DC reimburse for some form of live video in Medicaid fee‐for‐service.1

• 14 state Medicaid programs reimburse for store‐and‐forward. 4 others have laws but no mechanism yet. 1

• 8 states have policies specific to teledentistry.2

• Very few states have a policy environment that fully supports the range of possibilities to improve health and care using teledentistry.

1. Center for Connected Health Policy. State Telehealth Laws. Fall 2019. https://www.cchpca.org/sites/default/files/2019‐10/50%20State%20Telehalth%20Laws%20and%20Reibmursement%20Policies%20Report%20Fall%202019%20FINAL.pdf

2. National Conference of State Legislatures (NCSL). Increasng Access to Health Care Through Telehealth. May 2019. http://www.ncsl.org/Portals/1/Documents/Health/Healthcare‐Access_Telehealth_v03_web.pdf


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Space and Equipment


EHR: Radiographs


EHR: Photographs


Space and Equipment


Space and Equipment


Space and Equipment

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Space and Equipment



Radiographs


Photographic Template


Photographs


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Study onTelehealth vs In‐Person Decision

Making



Community‐based Prevention and Early Intervention Procedures


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The Virtual Dental Home Sites


Oral Health Systemsfor Underserved Populations


• Reach people, emphasize prevention, and lower costs

• Majority of people kept and verified healthy on‐site

– About 2/3 of children had all needed services completed by dental hygienist

• Continuous presence

• Community organization integration

• Dentist integration


The Virtual Dental Home Current Trainees

8‐ DentalQuestLearning Collaborative

19‐ DHCS DentalTransformation Initiative

1‐ Delta Dental

5‐ HRSA

1 – CA Wellness

2 – Regional Centers

2 – Hawaii3 – Oregon5 ‐ Colorado

Total = 46 entities


The Virtual Dental Home Current Trainees

8‐ DentalQuestLearning Collaborative

19‐ DHCS DentalTransformation Initiative

1‐ Delta Dental

5‐ HRSA

1 – CA Wellness

2 – Regional Centers

2 – Hawaii3 – Oregon5 ‐ Colorado

Total = 46 entities

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San Mateo County

91

2010 – 1 site in VDH Demonstration– Partner – IHSD Head Start Agency– 1 part time community team– East Palo Alto


Ravenswood Family Health Center









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Virtual Dental Home Consulting98

v

San Mateo County

2018 – 27 sites– Multiple agencies and schools– 2 full time community teams– Across San Mateo County


States Adopting Virtual Dental Home Systems2010

VDH Funded Projects

VDH Systems

VDH Discussions



VDH Funded Projects

VDH Systems

VDH Discussions



VDH Funded Projects

VDH Systems

VDH Discussions



VDH Funded Projects

VDH Systems

VDH Discussions

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Telehealth‐Connected Teams: Training







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There are several legal and regulatory issues that can either inhibit or facilitate realizing the potential benefits of telehealth‐connected teams to deliver oral health services.


Legal and Regulatory Environment

Ability to use telehealth

• Scope of practice laws, regulation, interpretation

– Ability of allied personnel to collect diagnostic records prior to a patient being seen by a dentist

– Ability of allied personnel to perform procedures in locations separate from dentists

– Understanding that dentists can develop a diagnosis and treatment plan without an in‐person visit with the patient


Dentist Examination

ADA CDT 2017 Definitions

• “Clinical Oral Evaluations”

– “… recognize the cognitive skills necessary for patient evaluation. The collection and recording of some data and components of the dental examination may be delegated; however, the evaluation, which includes diagnosis and treatment planning, is the responsibility of the dentist.”


Dentist Examination

ADA CDT 2017 Definitions

• “Clinical Oral Evaluations”

– There is nothing in these definitions that specifies whether data is collected and evaluated in person or not or whom it is collected by.

– The critical component is that it is the dentist’s cognitive skills used in interpreting the information that cannot be delegated and that must be performed by the dentist.

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Dentist Examination

• Study

• Experience

• Range of possibilities

• Calibration and communications



Ability to be paid for services performed using telehealth technologies

• Principle: consider telehealth technologies as communication tools, distinct from the health services that are being provided.

• Require payors to pay for covered services whether performed in‐person or with the use of telehealth technologies

• Include store‐and‐forward as well as real time



Ability to be paid for services performed using telehealth technologies

• Suggested language:

• “face‐to‐face contact between a health care provider and a patient is not required for services performed using real time or store‐and‐forward teledentistry.”


Everyone Benefits• Providers

• Public

• Policy Makers


Community Engaged Dental Care System


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What is a dental practice?

High cost surgical suite

Low cost community site


What is a dental practice?Linked Community/Clinic System

High cost surgical suite

Low cost community site


Dental Care in the Future

• Dental Practice =

– Geographically distributed

– Telehealth enabled

– Oral health teams

• Chronic disease management

– using biological, medical, behavioral, and social tools

• Integrated with general health, educational, and social service systems

• Interacting with the majority of the population

• Focused on oral health outcomes in the Era of Accountability


DeliverySystems

Measurement and PaymentSystems


Science


Paul Glassman DDS, MA, MBAAssistant Dean for ResearchSchool of Dental MedicineCalifornia Northstate [email protected]