Oral Health as Primary Care

Medicare does not cover routine dental care. That statutory fact is unchanged after sixty years of program history and multiple failed legislative attempts at reform. What has changed is the evidence base for what untreated oral disease costs, and the accountability structures that give ACOs, AHEAD hospitals, and MA plans financial reasons to care about a benefit they do not formally provide. For entities bearing financial risk for the total cost of care, the oral-systemic evidence is not academic. It describes a category of avoidable spending that is being generated by a gap in the benefit design they operate within.

The Clinical Evidence

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The relationship between periodontal disease and systemic health outcomes is one of the more studied areas of preventive medicine. It is also one where the evidence has had almost no effect on the insurance coverage structures that govern what most older Americans can access. That gap between the science and the policy is the operational context for every decision an ACO, hospital, or MA plan makes about oral health investment.

Periodontal disease and diabetes have a well-documented bidirectional relationship. Diabetes compromises the immune response to oral inflammation, increasing the prevalence and severity of periodontal disease. Periodontal disease, in turn, worsens glycemic control. A Cochrane systematic review concluded that conservative periodontal treatment is associated with a reduction in glycated hemoglobin of approximately 0.4 to 0.5 percentage points, and the authors noted that additional clinical studies are unlikely to change this conclusion. For a diabetic patient with an HbA1c of 8.5 percent, that is a clinically meaningful reduction. An estimated 25 percent of Medicare beneficiaries have diabetes, making this bidirectional relationship a population-scale cost driver for any entity managing a Medicare patient panel.

The aspiration pneumonia pathway is a separate and more acute risk. Dental plaque develops within hours of brushing and contains respiratory pathogens that, when aspirated, can cause non-ventilator hospital-acquired pneumonia. NV-HAP is the most common healthcare-associated infection in the United States; pneumonia is present in 65 percent of all healthcare-acquired pneumonia cases that are not ventilator-associated. For hospitalized Medicare beneficiaries, particularly those who are frail, post-stroke, have dysphagia, or have reduced salivary flow from polypharmacy, the aspiration risk is material. The VA’s HAPPEN project, which implemented standardized oral care protocols in hospital and long-term care settings, decreased pneumonia rates 40 to 60 percent at participating sites and is estimated to have saved over $100,000 in direct costs per prevented case. A separate hospital-level analysis reduced NV-HAP by 39 percent and estimated $1.72 million in cost avoidance in the first year alone.

The cardiovascular connection has a longer and more contested evidence trail. Epidemiological studies have associated periodontal disease with atherosclerosis, stroke, and cardiovascular events. The mechanism is plausible: oral bacteria can enter the bloodstream through inflamed gingival tissue and contribute to systemic inflammation. Whether treating periodontal disease reduces cardiovascular events in prospective trials remains an active research question, but the association is well established at the population level. A 2018 analysis estimated potential cost savings of $63.5 billion to Medicare beneficiaries with heart disease, diabetes, or stroke if periodontal care coverage were expanded to include an initial exam and annual treatment.

For entities bearing financial risk, the relevance of this evidence is not whether oral health is sufficient to warrant a standalone insurance benefit. The question is whether investing in dental screening and access for a high-risk attributed population generates enough reduction in medical spending to justify the cost. The answer is population-specific, but for patients with diabetes, cardiovascular disease, or documented frailty, the evidence supports that investment.

ACOs and Oral Health

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ACOs in the Medicare Shared Savings Program and ACO REACH operate under financial accountability for total cost of care. If dental-related avoidable hospitalizations, poorly controlled diabetes driven partly by untreated periodontal disease, and NV-HAP events appear in claims data, they reduce shared savings or increase losses under two-sided risk arrangements. The challenge is that ACOs historically have not tracked oral health as a performance domain. The data infrastructure to connect dental care access to medical cost outcomes has not been part of standard ACO reporting, and dental claims are not part of Medicare fee-for-service data.

The operational pathway for ACOs that want to act on the oral-systemic evidence runs through partnerships rather than direct benefit provision. ACOs cannot extend the Medicare dental benefit, but they can screen for oral health needs and create referral pathways to community resources. FQHCs with dental programs represent a natural partner in many markets: FQHC dental services are covered under the consolidated billing structure for FQHC visits, and FQHCs serve the low-income and dual eligible populations that tend to have the highest rates of untreated dental disease. An ACO with FQHC partners can incorporate oral health screening into care management outreach for high-risk patients with diabetes or cardiovascular disease and route those patients toward available dental resources.

For dual eligible patients, the ACO-Medicaid intersection creates additional leverage. Dual eligibles who are full-benefit Medicaid recipients may have access to Medicaid dental coverage depending on their state, though the scope of that coverage and the adequacy of the dental network vary widely. An ACO’s care management team identifying a dual eligible patient with untreated periodontal disease can work with the Medicaid care manager to ensure that any available dental benefit is used. This coordination is not standard practice in most ACOs and requires data sharing infrastructure between Medicare and Medicaid care management, but it is achievable under existing program authorities.

The larger structural opportunity for ACOs is MAHA ELEVATE. ACOs are among the explicitly eligible applicant categories for MAHA ELEVATE cooperative agreements, and the National Association of ACOs specifically noted that many MSSP participants already fund preventive and integrative care interventions using shared savings dollars. An ACO proposing to test a structured oral health screening and referral program, with nutrition and physical activity incorporated into a broader preventive intervention for patients with diabetes, could potentially design a MAHA ELEVATE proposal that builds the evidence base the ACO is already trying to generate internally.

AHEAD and Oral Health

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The AHEAD model, which operates in Connecticut, Maryland, Massachusetts, Minnesota, New Jersey, New York, and Vermont, pays participating hospitals global budgets designed to incentivize population health investment and avoidable utilization reduction. Under a global budget, every hospital admission that could have been prevented represents a cost that reduces the hospital’s margin. Dental-related emergency department visits and hospitalizations for oral infections, aspiration pneumonia, and poorly controlled diabetes with documented oral disease etiology are categories of avoidable utilization that AHEAD hospitals have a direct financial incentive to reduce.

Emergency department utilization for dental conditions is a well-documented phenomenon. Patients without dental coverage and without access to dental providers use emergency departments for dental pain, oral infections, and abscesses, where they receive symptomatic treatment but no definitive dental care. For AHEAD hospitals, this pattern represents both a cost and an opportunity: the ED visit is preventable, but preventing it requires connecting the patient to dental care that the hospital cannot bill for and that Medicare does not cover.

The practical responses available to AHEAD hospitals operate at the community partnership level. Hospital community benefit programs, which are legally required for nonprofit hospitals under the ACA, can fund dental screening in the ED and inpatient settings, partnering with dental schools, FQHC dental programs, or community dental clinics to provide follow-up care for patients with identified oral health needs. The discharge planning process is the most direct intervention point. A patient being discharged from a hospitalization for aspiration pneumonia, an oral infection, or a diabetic exacerbation should have oral health status assessed and, where disease is identified, a referral placed to a dental resource they can access. The hospital cannot bill for that referral, but under a global budget structure, preventing the readmission is the financial incentive.

AHEAD’s community benefit investment and health equity obligations also create a vehicle. All AHEAD participating states have substantial dual eligible and low-income Medicare populations, and the states themselves have interest in the evidence that total cost of care models can generate around preventive interventions. An AHEAD hospital that builds a systematic oral health screening program and tracks ED revisits and hospitalization rates for patients who received dental referrals versus those who did not is generating the kind of evidence that CMS’s innovation center has been seeking for cost-effectiveness of non-covered services.

MA Plan Dental Benefit Design

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For MA plans, the oral-systemic evidence creates a benefit design argument that is specific and financially grounded. The generic dental cleaning benefit that most MA plans offer as a table-stakes supplemental item has minimal clinical impact on the populations most likely to generate avoidable medical spending. Preventive cleanings for a healthy 68-year-old with no chronic disease are not the intervention with the highest ROI for a plan managing a population with 25 percent diabetes prevalence. Comprehensive dental coverage, including periodontal assessment and treatment, for a panel of diabetic patients who have not seen a dentist in two or more years is a different actuarial proposition.

The challenge MA plans face is demonstrating the ROI of dental investment under current rate compression. The 2025 plan year saw the first-ever decline in MA supplemental benefit value, driven largely by comprehensive dental cuts. Plans reduced dental allowances, moved comprehensive dental from mandatory to optional supplemental benefits, and narrowed dental networks. This contraction was driven by revenue pressure, not by evidence that dental spending had failed to generate medical savings. The data infrastructure to connect dental utilization to downstream medical cost performance at the plan level has not been built in most MA organizations.

The case for targeted dental investment is most clearly supported for D-SNP populations, where the dual eligible behavioral health and chronic disease burden is highest and where the alignment between Medicaid dental coverage and Medicare medical coverage creates some data-sharing possibilities. A D-SNP with a capitated Medicaid contract can potentially track both dental service utilization under the Medicaid benefit and medical cost outcomes under the Medicare benefit for the same population. Plans operating FIDE or HIDE SNPs with integrated care management have the organizational infrastructure to make this connection and the financial accountability to have an incentive to do so.

The argument that dental investment generates medical savings is supported by employer and commercial insurance data more than by Medicare-specific evidence. One study found that treating periodontal disease in patients with type 2 diabetes was associated with a 40 percent reduction in inpatient admissions, emergency room visits, and overall healthcare spending in that population. These findings from commercial populations are not directly transferable to Medicare, but they suggest the direction of effect and the magnitude of potential savings that targeted benefit design could pursue. MAHA ELEVATE’s evidence-generation mandate could, if an MA plan’s ACO partners or affiliated organizations win cooperative agreements, produce the Medicare-specific evidence base that would support benefit design changes in future plan years.

Related Reading

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MCR-05_05 ACOs and the Whole-Person Care Imperative: Behavioral Health, Oral Health, and SUD Integration MCR-01_08 AHEAD and Geo AHEAD: Geography as a Cost Control Lever