paul glassman dds, ma, mba professor and director of ... · teeth treated with complete caries...
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Paul Glassman DDS, MA, MBAProfessor and Director of Community Oral HealthUniversity of the Pacific School of Dentistry San Francisco, [email protected]
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Virtual Dental HomesContext and Rationale
• The evolving U.S. health care system• Trends in the U.S. oral health industry• Recognition that the major oral diseases are chronic diseases
• Scientific basis for sealing caries• Use of telehealth‐connected teams and Virtual Dental Homes
• Financing dental care in the Era of Accountability• Conclusions
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Health Care and Social Spending as a Percent of GDP 2013
The Commonwealth FundU.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countrieshttp://www.commonwealthfund.org/publications/issue‐briefs/2015/oct/us‐health‐care‐from‐a‐global‐perspective.
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
A Framework for Educating HealthProfessionals to Address the Social Determinants of Health
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Virtual Dental HomesContext and Rationale
• The evolving U.S. health care system• Trends in the U.S. oral health industry• Recognition that the major oral diseases are chronic diseases
• Scientific basis for sealing caries• Use of telehealth‐connected teams and Virtual Dental Homes
• Financing dental care in the Era of Accountability• Conclusions
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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
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U.S. National Dental Expenditures 2000 ‐ 2025 ($ Billions)
Dental Services (DS)
DS % of 2000 Level (321%)
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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=
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(Millions)
Medical Expenditure Panel Survey ‐ Top 25, 2013
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Oral Health Expenses
Source: Bureau of Labor Statistics: Consumer Price Indexhttp://www.bls.gov/cpi/cpi_dr.htm
100%
120%
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160%
180%
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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%)
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Health Centers and Underserved Populations ‐ 2015
Percent Number
Total individuals served by health centers 24,295,946
Total individuals receiving dental care 21.4% = 5,199,332
U.S. population 320,000,000
U.S. population not receiving dental care 65% = 208,000,000
Percent (%) of population served in health centers = 2.5%
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Virtual Dental HomesContext and Rationale
• The evolving U.S. health care system• Trends in the U.S. oral health industry• Recognition that the major oral diseases are chronic diseases
• Scientific basis for sealing caries• Use of telehealth‐connected teams and Virtual Dental Homes
• Financing dental care in the Era of Accountability• Conclusions
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Care for Chronic Oral Diseases
Acute Care/Surgical
Intervention
Chronic Disease
Management
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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)
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Virtual Dental HomesContext and Rationale
• The evolving U.S. health care system• Trends in the U.S. oral health industry• Recognition that the major oral diseases are chronic diseases
• Scientific basis for sealing caries• Use of telehealth‐connected teams and Virtual Dental Homes
• Financing dental care in the Era of Accountability• Conclusions
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
• Expert panel convened by ADA Council on Scientific Affairs• Sealants are effective in reducing occlusal caries incidence in
permanent first molars of children, with caries reductions of 76.3 percent at four years, when sealants were reapplied as needed. Caries reduction was 65 percent at nine years from initial treatment, with no reapplication during the last five years
• The use of explorers is not necessary for the detection of early lesions. Forceful use of a sharp explorer can damage tooth surfaces
• The clinician should use recent radiographs, if available, in the decision‐making process but should not obtain radiographs for the sole purpose of placing sealants
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
• The evidence supports the placement of sealants over non‐cavitated caries lesions in the pits and fissures of permanent teeth in children, adolescents, and young adults.
• This finding does not support reported concerns about poorer outcomes associated with the inadvertent sealing of caries and should lessen the reluctance of practitioners to provide sealants—an intervention proven to be highly effective in preventing caries.
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Qvist V, Borum MK, 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
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Incomplete Caries Removal
• 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.
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Incomplete Caries Removal
• 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
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Interim Therapeutic Restoration (ITR)
AAPD Policy on Interim Therapeutic Restorations (ITR)
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Virtual Dental HomesContext and Rationale
• The evolving U.S. health care system• Trends in the U.S. oral health industry• Recognition that the major oral diseases are chronic diseases
• Scientific basis for sealing caries• Use of telehealth‐connected teams and Virtual Dental Homes
• Financing dental care in the Era of Accountability• Conclusions
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
EHR: Radiographs
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
EHR: Photographs
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Space and Equipment
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Space and Equipment
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Space and Equipment
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Space and Equipment
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Space and Equipment
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Space and Equipment
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Space and Equipment
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Space and Equipment
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Radiographs
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Photographs
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Community‐based Prevention and Early Intervention Procedures
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
The Virtual Dental Home Sites
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Pacific Center for Special Care at the University of the Pacific School of Dentistry. Report of the Virtual Dental Home Demonstrationhttp://dental.pacific.edu/departments‐and‐groups/pacific‐center‐for‐special‐care/publications
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Oral Health Systemsfor Underserved Populations
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
• 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
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Hub and Spoke System
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
AB 1174
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
The ADA House of Delegates passed Resolution 45H‐2015, Comprehensive ADA Policy Statement on Teledentistry, in November at ADA 2015 – America’s Dental Meeting.
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Denti‐Cal Teledentistry Billing
Denti‐Cal Bulletin. March, 2016, V32, #4http://www.denti‐cal.ca.gov/provsrvcs/bulletins/Volume_32_Number_04.pdf
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
CPCA GuideIntermittent ClinicsDental Hygiene BillingTelehealth BillingDentist Contracting
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Proof of Concept
Legislation/Regulation
Expansion/Research
2009 2015 2016 +
OR, CO, HI,MN, AZ, MO...
OR, CO, HI
Virtual Dental Home Timeline
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Virtual Dental HomesContext and Rationale
• The evolving U.S. health care system• Trends in the U.S. oral health industry• Recognition that the major oral diseases are chronic diseases
• Scientific basis for sealing caries• Use of telehealth‐connected teams and Virtual Dental Homes
• Financing dental care in the Era of Accountability• Conclusions
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
The Era of Accountability
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
The Triple Aim
• improving the experience of care• improving the health of populations• reducing per capita costs of health care
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
The Quadruple Aim
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
Virtual Dental HomesContext and Rationale
• The evolving U.S. health care system• Trends in the U.S. oral health industry• Recognition that the major oral diseases are chronic diseases
• Scientific basis for sealing caries• Use of telehealth‐connected teams and Virtual Dental Homes
• Financing dental care in the Era of Accountability• Conclusions
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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
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Pacific Center for Special Care at the University of the Pacific Arthur A. Dugoni School of Dentistry
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Paul Glassman DDS, MA, MBAProfessor and Director of Community Oral HealthUniversity of the Pacific School of Dentistry San Francisco, [email protected]