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One more opportunity: Oral health coverage for seniors under Medicare

March 1, 2020
Without seeking the spotlight, senior citizens and senior care advocates are mobilizing to extend Medicare coverage to medically necessary oral health care.

Today’s seniors have shaped this country in so many ways. They won the Cold War, pioneered astonishing medical breakthroughs, built an economy that created millions of jobs, and achieved incredible technological breakthroughs. In every way imaginable, today’s seniors boldly led our nation in a positive direction. And it looks like they’re about to do so once again.

While headlines from Washington, DC, have been dominated over the past few months by impeachment and the 2020 national elections, something else of great significance is going on. Quietly and without seeking the spotlight, senior citizens and senior care advocates are mobilizing to make the Medicare program better. Specifically, they are working to extend Medicare coverage to medically necessary oral health care.

Our readers are already well informed about the chronic diseases that afflict millions of Medicare beneficiaries and cost our nation billions of dollars each year. It’s also well-known that untreated oral microbial infections are the driver behind many of these chronic conditions, including diabetes, heart disease, Alzheimer’s disease, and stroke. In fact, the scientific evidence is overwhelming. As documented by researchers and medical specialty societies, oral disease complicates and even jeopardizes medical treatments in many cases. Organ and stem cell transplantations can’t proceed, for example, if a patient is suffering from advanced oral disease. Likewise, heart valve surgery, cancer chemotherapies, orthopedic prostheses, and autoimmune disease management are all at risk if oral disease is present.

Although the evidence is clear about this critical need, most Medicare beneficiaries—including seniors and individuals with disabilities—do not have coverage for such care, even when it is crucial for treating Medicare-covered diseases. As illogical as it sounds, Medicare coverage extends to the treatment of all microbial infections except for those relating to the teeth and periodontium. There is simply no medical justification for this exclusion, especially in light of the broad agreement among medical specialists that such care is integral to the medical management of numerous diseases and medical conditions.

Adding to the illogic of current Medicare policy, a number of major insurance carriers already provide medically necessary oral and dental coverage to enrollees being treated for diabetes, heart disease, stroke, head and neck cancer, and organ failure. Those insurers know what Medicare has yet to discover: that providing this coverage reduces hospitalization and emergency department admission rates, substantially reduces overall costs, and promotes greatly improved health and well-being.

In a similar way, the Veterans Health Administration serves as a model for what Medicare should be doing. Many veterans receive treatment when their oral and dental diagnoses affect their medical prognoses. Just like the private insurers that are already providing medically necessary coverage, the Veterans Health Administration has experienced improved outcomes, lower costs, and greater client satisfaction. But despite all this progress, the Medicare program remains well behind, and every day it is experiencing the human and clinical cost of its inadequate policy.

There is a fiscal cost, too, because Medicare’s lack of medically necessary coverage is increasing the financial burden that’s being placed on Medicare, beneficiaries, and taxpayers. To determine exactly how heavy that burden is, the Pacific Dental Services Foundation commissioned an analysis by Avalere Health, a leading analytics firm based in Washington, DC. Avalere carefully examined retrospective claims analyses conducted by Aetna, Cigna, UnitedHealth, and United Concordia/Highmark. In addition, the Avalere specialists utilized leading data sources, including the National Health and Nutrition Examination Survey and the Medicare Expenditure Panel Survey, as well as a wide array of data reports and peer-reviewed studies. Their conclusion confirmed the findings of many: Avalere determined the fiscal burden of oral disease is so great that if Medicare provided medically necessary oral health care, the program would save an astounding $63.5 billion over 10 years.1 All of this underscores the imperative for action. 

As a further example, consider kidney transplantation. Today, kidney disease is the ninth leading cause of death in our nation, with one in five dialysis patients dying every year.2 Nearly 750,000 Americans suffer end-stage renal disease3 and 37 million are afflicted with chronic kidney disease. This is a population that is so large that nearly 20% of all traditional Medicare spending—$114 billion—is spent on them each year.2

Due to the alarming number of individuals afflicted by kidney disease, the Advancing American Kidney Health initiative was launched last July. This government-wide campaign aims to achieve a number of critical objectives, among which is doubling the number of kidneys available for transplant by 2030.2 More kidney transplants are desperately needed, of course, because nearly 100,000 patients are currently languishing on the waiting list.2 But it’s also true that many of those who make it to the top of the list are denied treatment due to untreated oral disease. According to the American Society of Transplant Surgeons and Society for Transplant Social Workers, many patients have dental problems that must be addressed before they can receive transplants: “Untreated dental problems can become deadly once a patient is immunosuppressed, so good dental care is a critical part of preparation for transplant.”4 For clinicians, the connection is self-evident: patients with kidney disease are often immunosuppressed, so oral infection not only risks systemic infection such as sepsis, but also organ rejection.

The time is now to make the connection equally clear to policymakers, and America’s senior citizens are once again taking the lead. According to a recent national poll, a strong majority of registered senior voters support action by Washington to provide medically necessary oral and dental coverage through Medicare. Importantly, this support spans income strata and is shared by Republican and Democratic seniors alike.5 This is crucial because senior voters have the power to sway November’s election. We last saw this in 2018, when millions of seniors departed from their traditional support for Republican candidates and enabled Democrats, with their focus on health-care initiatives, to become the House of Representatives’ majority party. We may see it again, if seniors choose to support the Democratic candidate for President.

As many in Washington are aware, the current administration has been taking action to woo seniors back to the GOP. In October, for example, the President traveled to a large senior retirement community in Florida to sign the Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors. Other policy changes are being undertaken, too, in order to earn favor among registered senior voters, and Medicare coverage of medically necessary oral and dental care could be among them. That’s the opportunity seniors and senior care advocates are pursuing right now. Via direct lobbying, strong community action, and a nationwide Make Medicare Better grassroots campaign, seniors and advocates are striving to close the Medicare coverage gap that currently threatens health and raises costs.

Building a Medicare that works better, meets more needs, and costs fewer dollars is a big challenge, to be sure. Fortunately, it’s one for which this extraordinary generation is already so well equipped. Because for America’s seniors, leading our country in this bold and positive way is just another opportunity to shape the country they and we all love.  

References

  1. Evaluation of cost savings associated with periodontal disease treatment benefit. Avalere Health. https://oralhealth.hsdm.harvard.edu/files/oralhealth/files/avalere_health_estimated_impact_of_medicare_periodontal_coverage.pdf. Published January 4, 2016. Accessed January 8, 2020.
  2. Advancing American kidney health. US Department of Health and Human Services website. https://aspe.hhs.gov/system/files/pdf/262046/AdvancingAmericanKidneyHealth.pdf. Accessed January 8, 2020.
  3. The kidney project. https://pharm.ucsf.edu/kidney/need/statistics. University of California San Francisco website. Accessed January 28, 2020.
  4. Medically necessary dental care. American Society of Transplantation website. https://www.myast.org/sites/default/files/documents/Medically%20Essential%20Dental%20Care%209.19.17.pdf. Accessed January 28, 2020.
  5. Freed M, Neuman T, Jacobson G. Drilling down on dental coverage and costs for Medicare beneficiaries. Kaiser Family Foundation website. https://www.kff.org/medicare/issue-brief/drilling-down-on-dental-coverage-and-costs-for-medicare-beneficiaries/. Published March 13, 2019. Accessed January 28, 2020.
Stephen E. Thorne IV is the founder and CEO of Pacific Dental Services. Follow him on Instagram @SteveThornePDS.

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