The Oncology-Oral Health Value Bridge: Put Your Money Where Your Mouth Is

Efforts to integrate oral and oncology care, and use of oral health measures in quality measurement and payment programs, would help improve care quality and patient outcomes, and reduce costs of cancer care. However, while payers and providers continue to develop and participate in innovative value-based models of oncology care, oral health is typically left out of the equation, leading to poorer patient outcomes and increased costs.

Oral health is a key component of whole-person health, but is often siloed from other medical care

Oral health acts as "a window to overall health" and is critical to maintaining whole-person health and wellbeing. Associations between dental and other diseases are well established and support the importance of integrating medical and dental care. For instance, oral health both impacts and is impacted by conditions such as cancer, osteoporosis, and diabetes. Unfortunately, the separation of medicine and dentistry is pervasive and impedes interdisciplinary collaboration to promote overall health outcomes and quality of life.

There have been limited efforts to integrate oral care and medical care, despite programs focused on conditions such as diabetes and pregnancy where the evidence supporting connections between dental and whole-person health has been firmly established. Calls to integrate dental care and medical care, as well as other types of care (e.g., behavioral healthcare), aim to improve quality of care and oral health access, as well as reduce care costs.

Oral care is essential to quality cancer care

Effective dental involvement in care for patients with cancer can enhance the value of cancer care by improving patient outcomes and reducing health care costs. Dental providers play a key role in the prevention and detection of certain types of cancers. According to a 2021 survey by the American Dental Association (ADA), cancer, precancer, and other neoplastic conditions are the second most common disease area monitored by dentists. Oral cancer screenings can lead to early diagnosis of oral cancer, which can significantly increase chances of survival. As “the first line of defense” against oral cancer, dentists can assess for and manage risk factors such as tobacco use, identify signs of oral cancer, and conduct treatment referrals.

Dental provider involvement is necessary to prevent and treat oral health complications from cancer treatment. More than one-third of individuals with cancer will develop complications that impact their oral health, such as infection, dry mouth, and jaw pain. Chemotherapy and radiation can increase patients’ risk of developing oral infection. Oral complications arising from cancer treatment negatively impact quality of life and may delay treatment. For instance, mucositis, a common side effect of cancer treatment, can cause pain, lead to systemic infections, delay chemotherapy, and limit ability to eat, speak, and take oral medications.

A dental evaluation before initiation of cancer treatment is important to identify and potentially resolve existing dental issues to reduce the risk of oral complications during and after treatment. During treatment, it is important for the dentist to be aware of medications and treatment, advise on the side effects, and support patients in maintaining dental health. Despite the clear need to integrate dental care into oncology care, integrated medical-dental cancer care is frequently not prioritized during cancer treatment.

Innovative approaches create a framework for integration of dental and oncology care

While dental care is not always prioritized in oncology care, there are examples that provide a framework for how to increase integration. Proven and promising approaches include patient and provider education, inclusion of dental providers on the oncology care team, co-location of dental and medical providers, and data sharing and communication between medical and dental providers.

For example, the Oral Health Nursing Education and Practice (OHNEP) Program at New York University School of Nursing is working to integrate oral health into nursing education programs and advance interprofessional collaboration. The OHNEP program has collaborated with GoMo Health to develop and integrate an oral health module into the GoMo Concierge Care oncology digital therapeutic, an evidence-based tool to support coordinated oncology care and patient engagement. The oral health module includes education for patients and care management messaging to prevent or manage cancer treatment-related oral side effects.

Permanente Dental Associates (PDA) has a long and successful experience with medical-dental integration, supported by data sharing across settings. PDA dental providers are often located close to Kaiser Permanente medical providers, providing further opportunities to engage patients in cancer screening and to coordinate other preventive and therapeutic care interventions. This approach has demonstrated success in closing care gaps, both medical and dental, among patients. PDA leverages quality measures (e.g., tobacco cessation referrals and interventions) to assess and monitor patient experience, quality of care, and outcomes, which inform dentist payment through a global payment model. Compared to the groups providing only medical care, PDA’s integrated medical-dental approach has yielded improved HEDIS measure performance.

Payers can play a role in driving and maintaining integration efforts by combining medical and dental insurance benefits and reimbursement. For instance, Anthem’s integrated medical and dental benefits have allowed for improved data sharing and care coordination to support improved patient outcomes and lower costs. Patients with cancer undergoing chemotherapy are automatically enrolled in a dental care plan with enhanced benefits and receive reminders about gaps in care.

While these initiatives are driving innovative integration, quality measures are needed to understand the opportunities for improvement and encourage collaboration between dental providers and oncology teams.

A quality measurement strategy to promote medical-dental integration

Several factors are converging to drive value-based oral health care (VBOHC) and medical-dental integration, including increasing interest in the oral-systemic health connection, high level of financial burden of dental care, growing number of individuals living with and surviving cancer, and focus on value in oncology. Widespread advancement of VBOHC has been hindered by the need to develop adult oral health outcomes measures and the limited use of established measures in current value-based care programs. Notably, key oncology quality improvement and value-based care programs have not historically included oral health quality measures, including in CMS’ PPS-Exempt Cancer Hospital Quality Reporting Program and Oncology Care Model, and the American Society for Clinical Oncology’s (ASCO) Quality Oncology Practice Initiative (QOPI).

Certain oncology clinical guidelines emphasize care coordination between dentists and oncologists, indicating a gap in measurement to assess quality of care. While the National Quality Forum has called for increased recognition through measurement of dental provider involvement in cancer prevention and detection as well as integrated care, there has been little movement to fill measure gaps. The Oral Health in America report, released by the National Institute of Dental and Craniofacial Research in 2021, further noted that while quality measures for programs integrating medical and dental care for individuals with chronic conditions are under development in some states, there is a gap in measures at the national level.

There is an opportunity to incorporate the role of dentists into new and current measures for quality payment programs, including preventive care and monitoring measures (e.g., cancer counseling and screening), oral health quality-of-life patient-reported outcome measures following cancer treatment, and utilization measures (e.g., avoidable emergency department visits). The Dental Quality Alliance has developed a condition-specific diabetes measure – oral health evaluation measure for adults with diabetes – that could serve as a template for a similar measure for adults with cancer.

In a new development, CMS’ Enhancing Oncology Model (EOM), proposed to start in 2023, includes enhanced funding for practices to provide additional services including patient navigation, presenting an opportunity to address oral health. Improved oral health navigation and care could support improvements in patient care outcomes and savings through integrated oral health and oncology care.

Given the importance of medical-oral care integration to cancer care, oncologists and dental providers should come together now to advance oral health for their patients.

About the Quality Outlook Commentary Series

Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Discern Health will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.

About Nina Regenold, MSc
Nina Regenold, MSc, is a Project Analyst at Discern Health. She brings a strong qualitative research background and knowledge of innovative, international, and multicultural care approaches to help clients improve care and navigate the health system. Nina’s recent work at Discern involves projects related to value-based care, policy, provider consolidation, and vaccination. 

  Prior to joining Discern, Nina worked with the Rapid Research, Evaluation and Appraisal Lab (RREAL) at University College London (UCL), where she conducted qualitative research with health care workers during COVID-19 and collaborated on a number of publications. Nina has program evaluation experience relating to peer- and community-based recovery models. She also has experience conducting health research across different levels, including individual patient experiences, specific cultural groups, health care providers, and larger health systems.  

About Kaitlyn Esselman, MHS
Kaitlyn Esselman, MHS, is a Director at Discern Health. She has a broad range of public health and policy knowledge, as well as extensive project management and data analytics experience. Kaitlyn helps clients understand the quality landscape specific to their therapeutic interest areas and identifies strategies for them to succeed in the evolving value-based care environment. Her recent work at Discern includes quantitatively assessing the performance of existing quality measures and examining the feasibility of potential new measures.

Prior to joining Discern, Kaitlyn was a policy analyst at the Hilltop Institute, where she conducted research related to vulnerable populations. She also managed the public policy and research programs at the National Sleep Foundation.

About David Blaisdell
David Blaisdell, a Director at Discern Health, leads and manages client projects, providing insight and subject matter expertise, particularly on quality landscapes and measure gap identification. David has led and contributed to projects focused on oncology quality measurement, most recently working with the National Pharmaceutical Council, as well as the Society for Immunotherapy of Cancer, to identify key gaps in measures used in accountability programs and opportunities for measure development. Through this experience, David can help clients navigate the oncology measure and value-based policy environment and define strategies for success.

In his time at Discern, David has led the review of the quality measurement and policy landscape for several therapeutic and topic areas and developed strategies for clients on opportunities to succeed within the value-based marketplace. David has led and contributed to projects convening multiple stakeholders, including providers, professional societies, patient groups, industry coalitions, and life sciences companies, to analyze gaps in measurement and define priorities for new measure development.

Before joining Discern, David was a legislative aide at the Massachusetts House of Representatives, coordinating constituent services and supporting policy analysis. Prior to this role, David served as Research Director for Voters Count, a voter advocacy nonprofit.

About Eva Lenoir
Eva Lenoir is a Project Manager at Discern Health. Eva leverages her experience in quantitative and qualitative methods and policy analysis to support Discern clients achieve their goals. Her recent work focuses on value-based care, health information technology, and quality measurement.

Before joining Discern, Eva was a Program Manager at the Maryland Health Care Commission where she collaborated on program development initiatives focused on advancing health IT to improve quality, safety, and equity of health care. Eva’s work included convening stakeholder workgroups to address policy changes, assessing the health IT landscape across provider types (e.g., skilled nursing facilities, home health agencies, urgent care centers), and creating educational resources for providers on health IT best practices and raising awareness of telehealth among consumers. Eva also managed projects assessing the effectiveness of select telehealth use cases in various care settings. Previously, she worked at the Johns Hopkins School of Medicine conducting behavioral pharmacology research, including controlled clinical trials on cannabis use for therapeutic purposes.

Blog Editor

About Tom Valuck, MD, JD
Tom Valuck is a Partner at Discern Health, part of Real Chemistry. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Discern includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace. 

About Discern Health
Discern Health, part of Real Chemistry, uses research and strategic advisory services to help our clients improve health and health care through value-based payment and delivery models. These models align performance with incentives by rewarding doctors, hospitals, suppliers, and patients for working together to improve quality while lowering total costs. Real Chemistry is an independent provider of analytics-driven, digital-first research, marketing services, and communications to the healthcare sector.