Sina Hedayatnia, BA1,2 and Donald B. Giddon, DMD, PhD3
1Harvard School of Dental Medicine, Boston, MA 02115, USA
2Harvard Business School, Boston, MA 02163, USA
3Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA, 02115, USA
Correspondence should be addressed to S.H. (Sina_Hedayatnia@hsdm.harvard.edu)
The United States is experiencing a dramatic shortage of primary care providers expected to worsen over the next decade, primarily from population growth and health care reform. The current environment fails to adequately diagnose the nation’s growing systemic health issues. Of the 80 million people affected by cardiovascular disease and 23 million people with diabetes mellitus, estimates suggest that one-third are unaware of their condition. Early screening for these and other conditions can elucidate risk factors for patients and help prevent disease through medical intervention and counseling.
One possible solution to the primary care gap is through the dentist’s office. Dentists are trained in all manners of systemic illnesses, especially those that manifest in the oral cavity. Both medical and dental communities increasingly accept the concept of the oral physician, a dentist who can provide medical screening and limited primary care. In order for dental professionals to widely endorse their necessary role as oral physicians, it is important to develop a business model that not only addresses oral and systemic health, but also remains sustainable in the current health care marketplace.
Here, we conduct a market analysis for the oral physician by estimating the population with undiagnosed health conditions who receive regular oral health care but not medical care, estimating the total costs of non-intervention in the form of medical costs, and developing practical models for dentists to address primary care in their practices.
The demand for primary care services in the United States is rising rapidly. Between 2005 and 2025, the number of patient visits to all primary care practitioners is expected to increase 29% due to population growth and an in increase in the number of elderly patients . Under the Affordable Care Act, the population of insured patients seeking care is expected to increase the patient pool by an additional 5–8%. Meanwhile, the number of primary care providers is expected to grow only by 2–7%, with more medical students forgoing primary care tracks in favor of higher paying, less demanding specialty positions . Compounding the problems associated with a paucity of providers is the misallocation of physicians, nurse practitioners, and physician assistants. Rural regions are generally the most underserved; these areas are served by 10% of the physician workforce, despite comprising 21% of the US population .
Coupled with the primary care shortage are millions of Americans who suffer from chronic systemic health conditions, often resulting in patients who fail to be properly diagnosed. 80 million Americans are recognized as having cardiovascular disease (CVD), while 23 million are affected by diabetes mellitus . Despite their widespread prevalence and associated health risks, it is estimated that one-third of these diseases remain undiagnosed. These conditions can be prevented by early intervention provided that a medical screening takes place before the disease onset. Interventions following screening for such diseases, leading to dietary changes and physical activity, have led to significant decreases in disease incidence .
Numerous authorities in the field of dentistry have endorsed the concept of the “oral physician.” An oral physician is a dentist or dental specialist with a complete knowledge of systemic health who can provide medical screenings and limited primary care. Dr. Donald Giddon, former dean of the New York University College of Dentistry, and Dr. Bruce Donoff, current dean of the Harvard School of Dental Medicine, among others, have supported dental curricula that go beyond the tooth and its supporting structures and go towards the pathophysiology and management of systemic diseases. Dentists and dental specialists are in a prime position to provide these services.
The connection between oral and systemic health is a topic of growing scholarly interest. Research in periodontal medicine is investigating effects of gum disease on cardiovascular and respiratory diseases, diabetes mellitus, and pregnancy . Systemic diseases can also have oral manifestations, as in the case of hematological disease, cancer, and autoimmune diseases . Interventions for smoking and diet management are already taking place in dental practices, given the role of cigarettes as a factor in oral squamous carcinoma and poor food choices as a risk factor for tooth decay. Some dentists consistently recognize and provide referrals for issues ranging from hypertension and skin cancer to domestic and substance abuse . Given the two-way relationships between gum health and general health, periodontists, who are specialists in supporting structures of teeth, are well suited to address systemic health concerns in their care for patients. Orthodontists, who specialize in treating dental malocclusions, build strong relationships with teenaged patients, often seeing them once a month for 2 years or more. As such, they may be capable of screening and counseling adolescent patients on developmental, eating, and behavioral disorders .
An interesting avenue for the dental profession to address primary care is through mental health. In addition to oral manifestation of psychological ailments, such as ulcers arising from lowered oral immune defenses under neurohormonal control, dental and craniofacial abnormalities can lead to depression and anxiety, especially in cases of body dysmorphic disorder and abuse . Interventions by a dental professional could be crucial in instances when a patient has been unaware of a problem or unwilling to seek out professional psychiatric care due to the stigma of mental health issues.
The dental community largely supports their rebranding as oral physicians. In a recent survey of US dentists, a majority of oral health professionals supported the incorporation of medical health screenings in the dental setting. 83.4% of dentists surveyed were willing to perform chair-side medical screenings, which would yield immediate results for diagnosis and management of CVD, diabetes, hypertension, human immunodeficiency virus (HIV), and hepatitis . Oral health professionals are unequivocally capable and willing to identify patients in the early stages of systemic disease and to offer prevention strategies. Furthermore, given that an estimated 19.5 million people in 2008 visited a dental practice and did not seek primary care services, dentists have an existing market for this new model of care .
Conducting a market analysis in addition to drafting a business model development for incorporating limited primary care into the dental practice has several implications. First, proven and sustainable business models could change the future education system and practice of dentistry as the evolution of dentists to oral physicians becomes more tangible. Rather than concentrating on the diagnosis and treatment of oral diseases, more dental programs and residencies would require students to attain a deeper knowledge of chronic, systemic health conditions and how to identify them. Second, integration of oral and systemic health in the dental setting would mitigate the current burden of primary care personnel shortages and improve systemic health out-comes through early diagnoses and subsequent referrals for treatment and lifestyle adjustments. Furthermore, successful implementation would lower overall health care costs and support national economic stability. Lastly, these models could also improve the state of oral health for mil-lions of individuals, as the option of having medical screenings could incentivize patients to seek regular dental care. These implications hinge on a practice model that takes advantage of the unique training of dentists, the availability of dental auxiliaries to handle minor procedures, and growing opportunities for primary care coordination among health professionals.
Part I. Market Analysis
In order to develop new practice models, it was important to understand the eligible target population of patients: the pool of patients who regularly see a dentist but not a physician (Figure 1). After isolating this patient group, we then determined the prevalence of undiagnosed health conditions as measure of the market demand for primary care screening performed by dentists. A market analysis was conducted using health and demographic data from the Center for Disease Control’s National Health and Nutrition Examination Survey (NHANES). Sample proportions used to estimate the exact number of susceptible patients were based on the US population. Data abstraction was performed using the SAS Universal Viewer software (SAS Institute Inc.) and Microsoft Excel.
The six leading causes of morbidity and mortality were used to quantify the eligible patient pool. These were diabetes, hypertension, hypercholesterolemia, obesity, tobacco use (smoking), and alcohol use. For each condition, we first determined the appropriate demographic for screening (i.e., women over 45 or adults 20 and over) and extracted the unique patient identifier numbers for that demographic from the 2003–2004 NHANES data. From this population, we then isolated the patients who denied having a diagnosis of, or receiving consultation for, the medical condition of interest. From this patient group, we then isolated those who received no medical care in the previous year by identifying the respondents who had answered “none” for the number of times they had received health care in past 12 months. “Health care” included visits to the doctor’s office, clinic, and/or the hospital emergency room. From this pool, we extracted the patients who received dental care in the last year by finding the respondents who answered “6 months or less” or “not more than 1 year ago” to the question, “How long has it been since you last visited a dentist.” This included visits to specialists and/or dental hygienists. Subsequently, we used the NHANES laboratory and medical evaluation data for that year to quantify the number of patients in the sample who did have a previously undiagnosed condition. Since this group received dental but not medical care in the last year, our sample represented the group of patients who could benefit from primary care screening by an oral physician.
Part 2. Costing Analysis
The most recent cost estimates for average life-long treatment associated with the afore-mentioned conditions were identified in the literature. Only direct costs, that is, those solely associated with medical treatments that pertain to the given health conditions, were assessed. These costs were multiplied by the estimated number of individuals with undiagnosed conditions who regularly visit the dentist and thus could benefit from medical screening(s) performed in a dental office. Combined, these costs represent the total economic burden for undiagnosed medical conditions for patients who have seen a dentist but not a physician in the last year. Costs to dentists and the US health care payer system for providing necessary screening and counseling services may be subtracted from the total economic burden in order to calculate the net potential savings that oral physicians can offer in terms of medical expenses averted. These latter costs require more sophisticated analyses and were not part of this work.
Part 3. Business Model Development
Potential models for dentists to address the primary care shortage were theorized based on the following criteria. First, a reasonable model must allow the dentist ample time within one visit to perform dental services as needed in addition to limited primary care screenings. Second, the model should address compensation for the oral physician, and third, the model should provide considerations for referrals, care coordination, and case management for the patients’ oral and system conditions. The following assumptions were therefore made in developing the oral physician practice models:
Traditional health insurance plans could not be used as a source of compensation due to practical constraints. Currently, medical and dental procedure codes are based on two different systems. Cross-coded claims are accepted by some carriers when screening Hb1Ac, CRP, HPV, and HIV, among other tests. Cross coding has had limited adoption by dentists, however, perhaps due to cumbersome medical coding and regulatory issues. Carriers may not allow dentists to screen for certain conditions. Additionally, some states have laws prohibiting dentists from certain screenings, such as HIV testing. Given these concerns, payment models for this new type of practice would have to rely on less conventional means of reimbursement.
Dentists and their staff are already well qualified and equipped for performing screening services. This is a reasonable assumption, as most, if not all, dental programs, including dental hygiene and assisting schools, educate students on screening principles for various health conditions. Dentists can provide additional education on pathophysiology and management of various health conditions for their staff and patients as needed. Screening tools such as glucose monitoring devices and blood pressure cuffs, if not already in the practice, require little investment and upkeep by the dental office as compared to imaging tools, handpieces, units, and other standard instruments of dental operatory.
Oral physicians and their auxiliaries will be able to successfully recognize the specific systemic health conditions from our market analysis and will be capable of making appropriate referrals to medical general practitioners and specialists to help manage these patients.
Part 1. Market Analysis
The market for diabetic patients was identified by those reporting no previous diagnosis of diabetes, in addition to having received dental care but no medical care within the last 12 months (Table 1). Pre-diabetes and diabetes were identified as having an HbA1c of 5.7 or higher.
For every dentist, there are five patients with undiagnosed pre-diabetes or diabetes. According to our analysis, there were approximately 7 million people in the U.S above the age of 20 who reported no diagnosis of diabetes, did not seek medical care in the past year, but did see a dentist in the past year. Of this group, 11.7%, or 783,043, were pre-diabetic or diabetic according to lab studies conducted by NHANES.
The United States Preventive Services Task Force (USPSTF) recommends blood pressure screenings for all adults 18 and over. Hypertension, defined as having a systolic blood pressure (SBP) of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher, is a key risk factor for stroke, heart attack, and heart failure. Additional complications stemming from high blood pressure include aneurysm of arteries, retinopathy, and end-stage renal disease.
To calculate the market for hypertensive patients, we included all men and women in the NHANES study over age 18 with the following criteria: (1) absence of medical history of hypertension, (2) did not see a physician (did not receive health care services) in the past 12 months, and (3) did see a dentist in the past month (Table 2). From this sample, we identified the group of patients who had undiagnosed hypertension as defined by the USPSTF criteria outlined above. Only individuals were with an average systolic pressure ≥140 mm Hg or diastolic pressure ≥90 were included in the target sample.
Our estimate for the total population who would benefit from hypertension screening by a dentist was 434,000, which includes patients whose systolic or diastolic blood pressures were in the hypertensive range.
High levels of LDL cholesterol can lead to atherosclerosis, which leads to the deposition of plaques in arteries. Progression of atherosclerosis in turn can lead to arterial stenosis or plaque rupture, both of which can culminate in complete arterial occlusion leading to myocardial infarction (heart attack) or stroke.
USPTF guidelines recommend lipid screening, including cholesterol measurement for all adults males ages 35 and above and all women ages 45 and above. Samples were therefore stratified according to Task Force guidelines.
A summary of results is presented in Table 3. Upon analysis of the laboratory data for men over 35, there were no men from this group who had undiagnosed hypercholesterolemia in terms of LDL level (LDL >160 mg/dL). While none of the members of the target group had high cholesterol (total or LDL), approximately 10% had high total cholesterol with borderline high LDL levels (130–159 mg/dL). The latter figure can be extrapolated to 67,370 males over 35 who have undiagnosed borderline high LDL cholesterol who may benefit from a lipid panel performed by a dentist.
When examining the population of women over 45, we found a sample of 21 people from 1,466 who had (1) not seen a doctor in the last year, but (2) had seen a dentist, yet (3) had never been diagnosed with high cholesterol. When extrapolated, this represents approximately 651,000 women over 45 who could potentially benefit from a lipid screening by a dentist. Upon analysis of the examination data, there were 3 of the 29 (14%) with either borderline high (130–159 mg/dL) or high (>160 mg/dL) LDL cholesterol levels. This can be extrapolated to 93,035 women over 45 with undiagnosed borderline high or high LDL cholesterol who could benefit from a lipid screening performed by a dentist.
In sum, this analysis estimates that 160,405 adults of the recommended age for cholesterol screening (men 35+, women 45+) have undiagnosed borderline-high to high LDL cholesterol. Upon including those who may have known about their cholesterol level(s) but see a dentist more often than a doctor, there were an additional 552,862 with borderline high to high LDL levels. Thus, dentists can potentially diagnose and/or monitor lipid levels for an estimated 713,267 men and women in the US.
A summary of results is presented in Table 4. Our estimate of all obese individuals (obesity defined as BMI greater than or equal to 30 kg/m2) receiving regular dental but no medical care was approximately 2.2 million. From this population, approximately 28% had never been told by a physician that they were overweight. Therefore, we conjecture that approximately 630,000 individuals could benefit from obesity screening and counseling by a dentist. A key assumption here is that a physician not telling these individuals that they are overweight also implies that they have never counseled their patients on weight loss.
A summary of results is presented in Table 5. Because there was no question in the 2003–04 NHANES regarding whether a physician had previously performed tobacco screening or offered tobacco cessation counseling, we used a proxy question: "Has a doctor ever told you had emphysema?" The question was chosen because emphysema, or chronic obstructive pulmonary disorder, is an illness that is directly caused by smoking (smoking comprises 80% of cases). If individuals are diagnosed with emphysema and are current smokers, it is safe to assume that the physician has offered tobacco cessation advice to those patients. This does provide a limitation in that individuals who may not have smoked for a long enough time would not have COPD, yet they still may have received counseling by a physician sometime before the last 12 months. Therefore, our analysis likely underestimates the number of patients who could benefit from cigarette/tobacco screening performed by a dentist. Nonetheless, this analysis estimates that there are approximately 2.23 million individuals who might benefit from tobacco screening/counseling by a dentist.
Because there were no questions in NHANES involving physician intervention regarding alcohol use, we used the proxy question: “Has a doctor or other health professional ever told you that you had any kind of liver condition?” Our outcome for diagnosing alcohol abuse was an incidence of drinking 5 or more drinks in one day. Using these criteria, we determined that approximately 2.23 million individuals might benefit from alcohol abuse screening by a dentist (Table 6).
Market Analysis Summary
Figure 2 shows the total populations representing the market for dentist-led primary care screenings for alcohol, tobacco, obesity, high cholesterol, hypertension, and diabetes. The three largest markets for medical screenings performed by oral physicians are in alcohol- and tobacco-using populations, as well as the diabetic/pre-diabetic population, which is approximately ~65% smaller. The smallest screening market for dentists is in the high cholesterol population.
Part 2. Costing Analysis
Summaries of the costing analysis are presented in Table 7 and Figure 3. Our costing analysis represents the consequence of dentists failing to perform primary care screenings in their offices. The strength of this assessment is that it uses the most up-to-date economic data regarding the direct medical costs of unaddressed systemic health conditions. Literature searches were conducted to determine a cost per patient in direct medical expenditures [8–12]. This cost was then multiplied by the market population estimate for each condition to determine the total economic burden for each condition.
Part 3. Business Model Development
Based on the assumptions presented in Part III of the Methods section, we devised two practice models that can allow the oral physician to provide quality oral health care in addition to primary care screening services: a concierge practice model and a “partner-practice” model contracted with an Accountable Care Organization.
The first model is a concierge practice. Concierge medical practices, as defined by the Annals of Internal Medicine, provide “expanded access to care and individualized attention, collect charges from insurance companies and directly from patients. Some bill hundreds of dollars for one-time ‘executive’ physicals, whereas others have patients pay annual retainer fees” . A concierge practice fits well with the roles of an oral physician. Patient subscriptions will be able to cover a myriad of benefits, from immediate phone/email access to the dentist to next-day appointments and complimentary services such as teeth whitening. Patients can still use their dental insurance for certain procedures. Best of all, the subscription will compensate the dentist for primary care screening activities. Increased fees generated by the concierge practice can be balanced by a reduction in the dentists’ patient pool. This will allow the oral physician to allocate ample time for providing quality dental treatments in conjunction with medical screenings. A schematic for this model is presented in Figure 4.
This concierge practice model is advantageous for patients desiring a premium level of dental care with the added benefit of general health screening. This type of practice may, however, exclude patients from lower socioeconomic backgrounds depending on the fee structure of the practice. Transitioning an existing dental practice into this oral physician model may also be difficult if patients must be dropped from the practice to decrease the size of the patient pool. Nonetheless, the concierge care model represents an innovative and attractive business offering for newly minted dentists to address the primary care conundrum of our generation.
The second model we developed can be best described as a “partner-practice” contracted with an Accountable Care Organization and is presented in Figure 5.
An Accountable Care Organization, or ACO, is a group of health care providers and institutions that is responsible for managing the health of a specific subset of patients. According to Marko Vujicic of the American Dental Association, “two essential features of the ACO are 1) designated accountable provider entities which share responsibility for treating a group of patients, and 2) performance measurement and new reimbursement mechanisms” . Oral health policy experts agree that dental care integration into ACOs would be an important step towards coordinating oral and systemic health care in an integrated effort while reducing health care costs. Despite this sentiment, dental-ACO arrangements are being challenged by the fact that dental care is not considered a core service in need of integration . Adult dental care is also not an essential health benefit under the insurance plans of most ACO patients.
Our model addresses these issues by allowing dentists to play a larger role in the overall health of an ACO patient pool. As ACOs move towards global per-patient budgets, dental offices that contract with an ACO can receive a portion of that budget for performing primary care screenings along with bonuses for correct diagnoses. Since the ACO itself would implement the entire infrastructure surrounding reimbursement and referrals, the oral physician would need little capital to adjust the practice model. Through shared financial risk, co-location, and electronic medical record technology, oral physicians could become part of a health care team that effectively coordinates oral and general health leading to reduced overall costs incurred by public insurance .
A potential drawback to the “partner-practice” model is that dental practice groups may have little influence in the coordination effort depending on how the ACO leadership views dental-medical integration. In addition, because ACOs are designed to address high-risk groups in the Medicaid and Medicare population, dental offices may not be able to keep up with the demand along with reduced reimbursement from government insurance programs.
Part 1. Market Analysis
Given the available data, our analysis represents the most accurate prediction of the market that can be targeted by dentists for primary care screening. However, several key limitations exist within this methodology. Foremost, the NHANES demographic and examination data were obtained in 2004. While more recent medical examination data were available, the 2003–2004 NHANES is the most recent survey that includes questions on dental care utilization, without which we would have been unable to identify our target market. It is likely that an analysis with current data on health care utilization and population health would yield different results, given the greater access to primary care offered to millions by the Affordable Care Act and potential changes in dental care utilization over the past decade.
One factor that confounds our analysis is that several data points in the NHANES survey are missing. For example, of the total 10,122 individuals in the survey, only 4,034 were tested for LDL-cholesterol, of which 416 individuals had missing values for their cholesterol data. In a sample of 6,213 individuals who were asked if their doctor had informed them of their high cholesterol level, 2,727 (44%) had no recorded response. That fact that such a large portion of our sample could not be measured suggests that our analysis most likely underestimates the market for cholesterol screening by dentists. A similar phenomenon occurred in the tobacco market assessment. In a sample of 5,041 people, there were 2,541 missing responses regarding smoking habits. Furthermore, when assessing the number of patients reporting a diagnosis of emphysema, there were 5,040 missing responses (52%) out of a possible 9,645. The extent of these missing data suggests a significant underestimation of the available market for tobacco screening by dentists. Missing data points also impinged upon the obesity market analysis. In a sample of 9,645 respondents, 4,605 individuals (47.7%) had no recorded response for the question, “Has a doctor said you were overweight?” Therefore, the population that stands to benefit from obesity screening/counseling by a dentist could be much larger than 630,000.
The market for primary care screening by dentists elucidated by this analysis is much smaller than it might be in practice. While these population estimates refer to individuals who are unaware of their condition, there is still potential for dentists to screen for individuals who have already received a diagnosis. A patient could have had high cholesterol in the past and might need continuous monitoring by a dentist is he/she regularly does not seek medical care.
Part 2. Costing Analysis
The costing analysis shows that dentists offering limited primary care services could save the health care market approximately $15.2 billion per year. It is important to note that the costing studies in our analysis each used different methodologies, and therefore the costs per patient per year relating direct medical expenditures may be variable according to disparate estimates for various medical procedures. Furthermore, one costing study was published in 2009 and another in 2000, which may alter the true medical costs of neglecting tobacco and alcohol abuse, respectively. Certain medical expenditures could have decreased due to technological advances or increased due to inflation.
In addition, it may not be possible for the dental profession to completely eliminate these diseases based on their diagnoses. First, dentists may not be able to screen for such conditions with perfect accuracy. Additionally, medical interventions are never completely successful. Lifestyle adjustments may take years to become fully ingrained, and medication efficacy is always determined by patient compliance. Furthermore, a dentist’s counseling may not be as strong an influence towards a healthier lifestyle as that of a medical physician.
Part 3. Business Model Development
The business two models presented above represent possible directions in which the oral physician can take if he/she endorses a comprehensive model of treatment focused on quality dental care along with limited primary care screening appropriate for the dentist’s training. We do not assert these are the only two models that can be best utilized by the oral physician. In fact, comprehensive care payment models, a blend of capitation (global budgets) and pay-for-performance measures, may be a better approach because they base a significant portion of the practice’s income on achieving valued outcomes and specific performance goals . Risk-adjusted payment models will incentivize care for those who need it most, while investments in technology and team-based care can improve the overall patient experience. Regardless of which practice model is ideal, the business models of the oral physician must be evaluated in a number of practice settings in order to address panel size, training, staffing considerations, scheduling and more. Insurance corporations and the Centers for Medicare and Medicaid Services should carry out these studies and disseminate their findings to dental schools, dental service organizations (DSOs), and dental professional organizations.
The purpose of this work was to identify the target market for the oral physician to address the United States primary care crisis. Using the most recently available national health statistics on dental and medical care access, including physical and laboratory examination data, we were able to identify a large segment of the population with undiagnosed health conditions, including diabetes, hypertension, hypercholesterolemia, obesity, tobacco use, and alcohol use. An estimated 6.5 million people have one of these conditions and are unaware of it. Because these people do not regularly seek medical care, they are vulnerable to progression and acute exacerbations of these conditions. This inevitably leads to increased mortality and increased medical expenditures, which largely come from the taxpayers’ pockets. However, many of these people who fall between the healthcare cracks do regularly visit dentists, placing dentists in a strategic position to address these gaps in care. Therefore, dentists must be able to redefine themselves as oral physicians and assume their responsibility for performing quality dental care in conjunction with limited primary care screenings.
The business of dentistry has been static for the past hundred years. Dentistry must adapt towards new and innovative delivery and financing models for the evolution of dentists into oral physicians. Prospective models include a concierge practice, which charges patients a retainer fee for holistic care, and an ACO-contracted practice that facilitates seamless referrals and care coordination with other medical professionals. If dentists and dental specialists are able to adapt to the changing climate of health care and become more involved in the systemic health of their patients, they will be able to save millions of lives and billions of dollars in avoided medical expenditures. Furthermore, dental practice innovation will undoubtedly lead to increased research efforts on the relationship between oral and systemic disease. It could also inspire more of our nation’s best and brightest minds to join the dental profession and make greater advances toward a healthier America.
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