A recent report by the DentaQuest Partnership for Oral Health Advancement and the National Association of Community Health Centers argues that because they are advancing integrated care that includes behavioral and oral health, Federally Qualified Health Centers (FQHCs) are well positioned to implement value-based care models that take a more holistic approach to care.
Among the report’s findings are that FQHCs treat more than 28 million patients annually, and dental care is included at approximately 81 percent of FQHCs nationwide.
Adults receiving oral health services at FQHCs are more likely to have better diabetic health status: for every 1 percent increase in FQHC patients receiving dental services, the proportion of patients with uncontrolled diabetes declined 0.2 percent.
Although they often struggle with funding, FQHCs actually are well-positioned to help state and federal agencies demonstrate the impact of value-based care because their electronic health records often integrate oral care, which makes data collection easier, the report says.
In a recent interview, Sean Boynes, D.M.D, vice president of health improvement for DentaQuest Partnership for Oral Health Advancement, said that although this movement is still in its infancy, “there are models available, and FQHCs could certainly talk with state Medicaid agencies or other payers in their state about contracting in a value-based design.”
Boynes oversees the DentaQuest Partnership’s programs and initiatives focused on the integration and coordination of person-centered care, developing and implementing value-based oral health strategies and operations, and evaluating and testing metrics for oral health measurement. The DentaQuest Partnership is affiliated with DentaQuest, an oral health benefits company responsible for approximately 30 million Medicaid individuals in 27 states.
Boynes said that when you look at the successful value-based care models, there is a convergence between medical, dental benefits, and behavioral health. “It is when you are able to achieve holistic care that you have success in the value-based care model. If you are siloing dentistry, and just doing pay for performance, then those models tend not to be successful, nor can they advance. The way this works is really a step-wise process. It takes about two years to get to what we would consider good access and good utilization numbers that reduce costs. We are saying in FQHCs, because they are holistic and you can get comprehensive medical, dental and behavioral care, that is the path to improved health and cost savings.”
Boynes referred to the finding about a correlation between the increase in FQHC patients receiving dental services and the decrease in uncontrolled diabetes. “If you consider the fact that uncontrolled diabetics cost between $9,000 and $15,000 per year, and controlled diabetics are around $4,000, you can do the math and start to see the savings possible,” he said. The CDC has noted that if dentists were to start screening appropriately for diabetes, heart disease and high cholesterol, it would result in about $100 million per year in savings, he added.
Some people may be surprised to hear that FQHCs have EHR interoperability between oral health and other disciplines. However, Boynes said, providing oral health is part of the scope of practice of FQHCs, so it has to be considered in EHR processes.
“Most dentists do not have EHRs; they actually have practice management software,” he said. “On the FQHC side, the dentist is there to help close care gaps and to facilitate more screenings and do risk stratification. Many FQHCs are using Epic and Cerner implementations that have dental components that allows them to improve care coordination. It is that care coordination where they can do a warm handoff or a direct referral without having to fax or make a phone call. They are able to do it electronically, which makes it much more manageable.”
The COVID emergency has pointed up that FQHCs have been much more efficient at teledentistry than other dental providers, Boynes said. “It is mostly because they were already using it as an outreach mechanism. They were providing asynchronous care in virtual dental homes, often in rural settings. A dental hygienist or therapist goes into the community and does cleanings, evaluations and takes X-rays that are loaded up into the cloud, and then sent to a dentist back at the hub. He or she creates a treatment plan and sends that back out. If the patient needs surgery or a filling, they come in to the site, but otherwise they are managed in the community at reduced cost.” In areas where the initial COVID surge has subsided a bit, these FQHC programs are much more likely to continue a level of utilization, whereas in private practice, reports are that teledentistry is decreasing as people come back into the office. “We are seeing stabilization in the safety net where that is continuing,” he said.
One area where more work is needed, the report says, is in consensus on outcome measures. “There is a lack of consensus regarding oral health outcome measures, and historically electronic dental record and practice management systems have not been equipped to monitor patient outcomes,” it says. “Additionally, how FQHC stakeholders, providers and administrators measure for value in care varies widely. However, FQHC dental programs could leverage the health information technology capabilities of their medical departments to become innovators in measuring the impact of oral health on overall health. Coupled with technology infrastructure and higher utilization of electronic health record management, FQHCs are positioned to change from an encounter-based system toward increased community-based oral health care delivery within a patient-centered medical home.”
Boynes said that there are measures in place around topics such as reducing surgical interventions or reducing sugar consumption, but there is still a need for greater consensus. “Where we are struggling as a profession is agreeing on what measures to put in place. Part of that disagreement involves a philosophy change that is starting to occur where people are looking at an oral health mechanism vs. a dental mechanism.”
The report drives home that FQHCs are more likely to see sicker patients than anyone else in the dental realm, Boynes said. The patients have a multitude of additional chronic conditions, ranging from heart disease and diabetes to active cancer. “They also see more emergencies, which may demonstrate they are good diversion sites for emergency departments for nontraumatic dental care, which is a cost sink and not a good value for the taxpayer at all.”
“We are finding that in the Medicaid space FQHCs are doing the best job of keeping people healthier and doing the best job of holistic treatment with the most difficult patient population,” Boynes said. Oral health is really an understanding that if you have a disease in your mouth, you have a disease in your body, he added. “FQHCs are well ahead and are actually leading the transformation to holistic care. We think from a value-based design standpoint, they are primed for it. NACHC looked at it with us and said we are ready to endorse this process.”