Abstract
Establishing reliable access to dental services for publicly insured patients is an important part of achieving equitable oral health care. In 2023, an oral health screening requirement was added to the MassHealth Accountable Care Organization contract, which has the capacity to affect over 1.3 million members enrolled in MassHealth Accountable Care Organizations throughout the state. The goal of the oral health screening requirement is to identify MassHealth-insured patients who do not have reliable access to dental services and to provide them with resources to establish a dental home with a MassHealth-participating dentist. Primary care providers were surveyed, and results indicate a need for a care coordination mechanism to assist MassHealth-insured patients with establishing a dental home, in addition to an option to request telehealth-enabled and/or urgent dental appointments. This report describes the oral health screening program at one MassHealth Accountable Care Organization and presents some of the data collected during the first year of its implementation, in addition to discussing how this data is being used to guide equity-focused interventions with the potential for policy implications.
INTRODUCTION
The 2021 National Institutes of Health (NIH) report “Oral Health in America: Advances and Challenges” described promising advancements in the delivery of oral health care, emphasizing the importance of medical-dental integration to facilitate access to some dental services in non-traditional settings, especially for patients who face barriers accessing the dental system. However, establishing reliable access to dental services, or a “dental home”, defined as “an ongoing relationship with a dentist,” as distinct from the delivery of some dental services in non-traditional settings, is an important part of achieving equitable oral health care. A lack of reliable access to dental services or a dental home may result in long-term, cumulative impacts on oral health, necessitating deferral of care and increasing reliance on advanced, less affordable dental services, consequently exacerbating health disparities for communities disadvantaged by the dental system.1 Favorable health care policies, strategic partnerships between government agencies, communities, clinical and academic leaders, in addition to financial support from stakeholders lay the foundation for systemic shifts that prioritize the establishment of a dental home as a routine component of a patient’s overall health care.1-3
In 2023, a major policy change occurred in Massachusetts that brought dental services to the forefront of primary care when an oral health screening requirement was added to the MassHealth Accountable Care Organization (ACO) contract.4 MassHealth, the combined Medicaid and Children’s Health Insurance Program in Massachusetts, introduced the ACO model in 2018, with the current extension due to run until 2027. As of June 2023, over 1.3 million members had enrolled in one of MassHealth’s ACOs, accounting for over half of MassHealth’s total 2.4 million memberships. The ACO model is operational through 17 MassHealth ACOs, with 20 affiliated community partners who work with ACOs to assist with enhanced care coordination in specific domains. The ACOs are provider-led entities responsible for coordinating comprehensive health care services for their enrolled members, which in the context of the new oral health screening requirement, includes ensuring access to MassHealth’s dental services for both adult and pediatric members. The oral health screening requirement is part of the new primary care sub-capitation payment to MassHealth ACOs, which is a monthly, per-member payment to cover a defined set of primary care services.5 The focal point of the oral health screening requirement lies in identifying patients who do not have reliable access to dental services and providing them with resources to establish a dental home. This short report describes the oral health screening program at one MassHealth ACO, in addition to data that has been collected during the first year of its implementation and how this data is being used to guide equity-focused interventions with the potential to impact policy.
Oral Health Screening Program at Cambridge Health Alliance
Tufts Health Public Plans, Inc., and Cambridge Health Alliance (CHA) formed an Accountable Care Partnership Plan, a type of ACO, with the aim of improving care integration and delivering high-quality health services to a MassHealth-insured population. Cambridge Health Alliance is a non-profit health care system in Massachusetts and serves as a major health care provider for communities in the cities of Cambridge, Somerville, and Boston’s Metro North region. The CHA operates three hospitals with emergency room/urgent care access, three pharmacies, more than ten primary care clinics, several outpatient specialty clinics, in addition to two community behavioral health centers and one dental clinic. It functions as a safety-net system and provides health services to over 140,000 patients, approximately 40,000 are enrolled in the MassHealth ACO. The patient population is racially/ethnically diverse and primarily from low-income minority backgrounds, with more than 40% receiving care in languages other than English, and approximately 60% with public insurance. As part of the new ACO contract, CHA launched an oral health screening program at all primary care sites in July 2023.6-7
The oral health screening program at CHA consists of one question that is asked to adult and pediatric patients attending primary care office visits, “In the past 12 months, have you visited a dentist or oral health care provider?” If the patient answers “No”, it is deemed a positive screen. Patients insured by MassHealth who screen positive are given instructions from masshealth-dental.net on how to find a dentist that accepts MassHealth to establish a dental home. Primary care providers (PCPs) may also place an internal dental referral on the electronic health record (EHR), which generates a referral to CHA’s dental clinic which offers a complete range of dental services, includes several MassHealth-participating dental providers and may serve as a dental home for some patients. However, the dental clinic at CHA is not large enough to meet the access needs of the entire patient population across all primary care sites. As such, when PCPs place an internal dental referral on the EHR, a list of contact numbers for other dental facilities in the region is also generated for the patient. This list includes contact information for dental schools, dental hospitals, and dental practices. However, best practices suggest that primary care clinics should identify supportive dental partners in the community that meet the specific needs and preferences of its empaneled patients. In a safety-net health care system, factors such as transport options, language preferences and the acceptance of public insurance must be prioritized in a primary dental care referral network.
Primary Care Provider’s Perspectives on Access to Dental Services
As part of the oral health screening program, data are being collected and analyzed, including the proportions of positive and negative screens among various population demographics, and will be presented in a separate publication. In addition, data have also been collected from PCPs in the Departments of Family Medicine, Internal Medicine, and Pediatrics through a 7-item survey. The survey used a five-point Likert scale to allow participants to express how much they agreed or disagreed with a particular statement. Anonymity was provided to participants to reduce social desirability bias.9 The survey assessed PCP engagement with, and perspectives on the current dental referral system, including perspectives on the mechanism being used to establish a dental home within the context of the oral health screening program. Providers were asked about their current dental referral practices, including their level of satisfaction with the EHR-based dental referral system, their level of confidence in both their ability and their patients’ abilities to find a dental provider who participates in MassHealth, and their likelihood to utilize an EHR-based dental referral order for care coordination, e-consult, telehealth-enabled and/or urgent dental appointment requests.
In total, 163 PCPs, comprising physicians, physician assistants, and nurse practitioners were contacted from the departmental distribution lists via a recruitment email sent by a gatekeeper. Of these, 52 responses were received electronically and recorded anonymously, yielding a response rate of 32%. Most respondents (78.8%) were physicians, while the remainder were physician assistants or nurse practitioners. Approximately half of all respondents reported placing EHR-based dental referrals at least monthly, with one-fifth of PCPs doing so on a weekly basis. However, most respondents reported dissatisfaction with the current dental referral system and expressed low levels of confidence in both their ability and their patients’ abilities to find a dental home with a MassHealth-participating dental provider in the context of a positive screening result. Indeed, providers indicated a strong inclination towards utilizing a care coordination mechanism to help patients establish a dental home, along with a preference for the option to request a telehealth-enabled or urgent dental appointment. Conversely, providers expressed less interest in an e-consult option for advice concerning dental issues. In summary, providers lacked confidence in the current mechanism being utilized to assist MassHealth-insured patients with establishing a dental home and providers would be likely to utilize a care coordination mechanism to assist MassHealth-insured patients with establishing a dental home, in addition to utilizing an option for telehealth-enabled and/or urgent dental appointment requests.
Equity-Focused Interventions and Policy Implications
The value-base care model used by ACOs aligns financial incentives with improvements in care coordination and integration across disciplines, thus prioritizing prevention and population health, which has the potential to improve health outcomes for patients at increased risk for health disparities.10 In the MassHealth ACO model, primary care clinics are classified as being in one of three tiers, representing increasing levels of care coordination and integration. Primary care sub-capitation payments to ACOs increase with tier level and are higher in all tiers for pediatric members relative to adult members. Tier one requirements are considered foundational, and clinics participating in a MassHealth ACO must meet tier one requirements.5
Oral health screening is a tier one requirement, as is the application of fluoride varnish for pediatric patients aged six months to six years. Behavioral health is another domain that has multiple tier one requirements including behavioral health screening (e.g. Patient Health Questionnaire-9) and behavioral health referral with bi-directional communication, tracking and monitoring. The latter requirement is similar to the oral health screening requirement because both request that the primary care clinic supply a list of local and reasonably accessible providers who are within the MassHealth network to patients who either require behavioral health or oral health integration. For behavioral health, the list of local providers must facilitate bi-directional communication with the primary care clinic, which can be enabled through various modalities such as the EHR, phone, or fax. The behavioral health domain also has multiple tier two requirements including a brief intervention for behavioral health conditions or identified behavioral health needs and establishing a telehealth capable behavioral health referral partner. Regarding the provision of brief interventions for patients with identified behavioral health needs, these can be conducted by a PCP or by an integrated member of the primary care team, such as a Licensed Independent Clinical Social Worker (LICSW). Regarding the provision of a telehealth capable behavioral health referral partner, there must be at least one behavioral health provider capable of providing telehealth among its local and reasonably accessible list of behavioral health providers who are within the MassHealth network.4 As noted previously, ACOs can also receive assistance from affiliated community partners if enhanced care coordination is required for behavioral health conditions.5
Within the context of the current oral health screening program, survey results indicate a necessity for a care coordination mechanism to assist MassHealth-insured patients with establishing a dental home, alongside the provision of options for telehealth-enabled and/or urgent dental appointments. This stakeholder feedback emphasizes the imperative for equity-focused interventions to be designed and piloted accordingly. Analyzing population health data is crucial to identify the groups of patients most in need of assistance with establishing a dental home. Given the various tiered requirements for behavioral health, a compelling argument emerges for implementing higher-tiered oral health requirements. For example, a brief behavioral health intervention administered by a LICSW is a higher tier requirement in the MassHealth ACO model.
Studies have shown that dental hygienists can be successfully integrated into primary care teams.11-13 As such, akin to behavioral health, a brief oral health intervention provided by dental hygienists could be a similar higher-tier requirement in the MassHealth ACO model for certain patient populations with identified oral health needs, such as young children, pregnant women, patients with diabetes or those at an increased risk for oral cancer.11-15 Additionally, by providing PCPs with the ability to request telehealth-enabled dental appointments, patients would be able to establish a virtual dental home from the primary care office visit if desired. This is particularly relevant in the context of a safety-net health care system, where factors such as transport options, language preferences and the acceptance of public insurance can put patients at an increased risk for health disparities.8,10
Accountable Care Organizations may also have the potential to engage with community partners for enhanced oral health care coordination, similar to their involvement with behavioral health care coordination, while simultaneously cultivating primary dental care referral networks, which is critical given the often siloed perception of dentists by the rest of the primary care team.16 Continual data collection and feedback from key stakeholders, including input from health care staff and patients, particularly those from underrepresented or historically marginalized communities, are imperative as equity-focused interventions are implemented, while providing generalizable knowledge that may be crucial for policy makers and health care systems striving to advance oral health equity.
CONCLUSION
The oral health screening requirement in the MassHealth ACO contract presents an enormous opportunity for equity-focused interventions with the potential to increase access to dental services for publicly insured patients in Massachusetts. The case for higher-tiered oral health requirements in the MassHealth ACO contract, akin to those for behavioral health, is compelling, given the expressed need for enhanced care coordination and options for telehealth-enabled and/or urgent dental appointments. Continual stakeholder engagement and data collection should be prioritized to inform equitable policies and practice recommendations.
DISCLOSURES
John Ahern received partial funding from CareQuest Institute for Oral Health.
Footnotes
NDHRA priority area, Population level: Health services (community interventions).
- Received May 27, 2024.
- Accepted June 1, 2024.
- Copyright © 2024 The American Dental Hygienists’ Association
