13
Reframing the System

Two panels of experts discussed the roles of different stakeholder groups effecting change to improve the access to oral health care services. Panelists were asked to discuss opportunities for providing leadership to change the oral health care system, including their leadership imperatives and tools that can move the system forward to serve everyone; to be more affordable, accessible, equitable, accountable, and culturally competent; and to be more integrated and interdisciplinary, recognizing the capabilities of all members of the oral health workforce. These discussions represented the panelists’ individual perspectives on how their sectors can provide leadership.

FEDERAL GOVERNMENT

Health Resources and Services Administration

Marcia Brand, Ph.D.

Health Resources and Services Administration


The Health Resources and Services Administration (HRSA) funds health centers, provides grants to support training and health workforce planning, and provides many other grants for maternal and child health and HIV and AIDS workforce issues. There are a number of things HRSA is already engaged in that can be built upon. First, HRSA can continue to promote the health center model that integrates medical and dental homes into a health home. Second, HRSA can encourage interdisciplinary education and



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13 Reframing the System Two panels of experts discussed the roles of different stakeholder groups effecting change to improve the access to oral health care services. Panelists were asked to discuss opportunities for providing leadership to change the oral health care system, including their leadership imperatives and tools that can move the system forward to serve everyone; to be more affordable, accessible, equitable, accountable, and culturally competent; and to be more integrated and interdisciplinary, recognizing the capabilities of all members of the oral health workforce. These discussions represented the panelists’ individual perspectives on how their sectors can provide leadership. FEDERAL GOVERNMENT Health Resources and Services Administration Marcia Brand, Ph.D. Health Resources and Serices Administration The Health Resources and Services Administration (HRSA) funds health centers, provides grants to support training and health workforce planning, and provides many other grants for maternal and child health and HIV and AIDS workforce issues. There are a number of things HRSA is already engaged in that can be built upon. First, HRSA can continue to promote the health center model that integrates medical and dental homes into a health home. Second, HRSA can encourage interdisciplinary education and 0

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08 THE U.S. ORAL HEALTH WORKFORCE training through health education centers and geriatric programs. The new patient navigator program, which helps enable people work through the health care system, may also be of use to the oral health system. HRSA may also be able to tap into its relationships with state offices of rural health and primary care associations to examine what is working at the state level and look at the impact of the economic downturn on access to oral health care services, professional groups, and education and training institutions. HRSA may have a role in improving access to oral health care services by increasing the amount of available data. Historically, HRSA has done a lot of work with different segments of the health care workforce, and so might be able to engage even more with oral health professionals. In addi- tion, the Health Workforce Information Center provides a single portal for accessing information on the health care workforce and enables different groups to share information on upcoming meetings, funding opportunities, reports, and best practices. Finally, HRSA has a mediation role. HRSA will be working with the new administration as it engages in health care reform; oral health needs to be kept as a part of that discussion. HRSA may also act as a convener to bring people together to continue to engage in dialogues about improving access to oral health services. Centers for Medicare and Medicaid Services A. Conan Dais, D.M.D., M.P.H. Centers for Medicare and Medicaid Serices The Centers for Medicare and Medicaid Services (CMS) is a partner- ship between the federal government and the state Medicaid agencies, creating a sharing of responsibilities. The states drive a number of the initiatives that take place in Medicaid to establish eligibility and establish the scope of services to be provided. States also establish payment rates that are then matched by the federal government providing they fit within federal guidelines. CMS has a number of oversight responsibilities from the federal level. CMS is a payor and must abide by federal guidelines and regulations regarding payment. For example, the Code of Federal Regulations basically defines dental services as being provided by a dentist or someone supervised by a dentist. A number of new programs license other types of professionals to deliver oral health services. When a state licenses a nondentist profes- sional to provide these services, there is a mechanism in the regulations that allows CMS to approve those professionals to be compensated if the State Medicaid Agency chooses to cover them. However, complications can arise. For example, the Early Periodic Screening Diagnosis and Treatment

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0 REFRAMING THE SYSTEM (EPSDT) program requires the provision of dental services to all Medicaid- eligible children, but defines those dental services as being done by a dentist with referral to a dental office. While services can be provided and compensated in alternative settings, the EPSDT requirements are not fully met under these circumstances, and there still need to be linkages back to a dental office or dental clinical facility anyway. The new Children’s Health Insurance Program (CHIP) legislation requires coverage for children in that program, so similar complications or issues may arise.1 CMS will also be involved in health policy discussions if health care reform is enacted. CMS was integrally involved regarding the Medicare Modernization Act2 and will surely participate should health care reform be enacted. CMS has also encouraged the formation of a Dental Quality Alliance by the professional dental organizations to propose dental quality measures development. This alliance will become very useful since the Children’s Health Insurance Program Reauthorization Act calls for these measures to be developed soon. STATE DEPARTMENT OF HEALTH Amy D. Cober, M.P.H., RD, LD Florida Department of Health The Florida Department of Health (FDOH), headed by Florida’s State Surgeon General, has a mission to promote, protect, and improve the health of all people in Florida. In addition, the State Surgeon General tasked the FDOH overall to address prevention, preparedness, and personal respon- sibility. Within oral health, the FDOH has developed a state oral health improvement plan for disadvantaged persons, a comprehensive plan devel- oped through a collaborative process between the public and private sectors that is working towards the development of an integrated, coordinated oral health system. Florida is unique among states in that local county health departments are a large part of the safety net, providing clinical operations and directly employing dentists, dental hygienists, and dental assistants in operatories throughout the state. Cober stated that the FDOH provides almost one- third of the Medicaid oral health services that are provided in the state of Florida, and these services are primarily for pediatric patients. However, Florida is like many other states in that there are large areas of under- 1 Children’s Health Insurance Act. Public Law 111-3. 111th Cong. (2009). 2 Medicare Prescription Drug, Improvement, and Modernization Act. Public Law 108-173. 108th Cong. (2003).

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0 THE U.S. ORAL HEALTH WORKFORCE served; for example, only 6 of 67 counties in Florida do not have a dental health professional shortage area designation, and 43 of the counties have the entire county designated as a dental health professional shortage area (FDOH, 2008). The State Health Office is active in promoting and monitor- ing community water fluoridation. In Florida, 79 percent of the community water systems are fluoridated, and 71 percent of the population has access to fluoridated water in their homes (personal communication, A. Cober, Florida Department of Health, May 5, 2009). The FDOH is also involved in improving oral health care through data collection and analysis, looking to Medicaid data, data collected through community dental health projects, and fluoridation data. Additionally, it has a role in the licensing and regulation of numerous health care profes- sions including dental health professions through the Medical Quality Assurance Division. One of the leadership roles state health departments can provide is to educate legislators, dental organizations, and their boards of dentistry about the specific state-level workforce challenges and opportunities for improving access. For example, the FDOH is looking at statutes and work- ing with state legislative staff on issues such as including data surveys in the licensure renewal process to gain knowledge about the current dental workforce and to design initiatives to assist with recruitment and retention. Second, health departments may facilitate collaboration among disciplines. The FDOH received a HRSA grant to establish the Oral Health Florida Coalition, which has been instrumental in bringing multisector partners together and creating new opportunities. The coalition has work groups in maternal and child oral health, special needs populations, fluoridation, and elder care. The FDOH also encourages and assists the facilitation and development of local coalitions, as there is much important work to be done at the local level. The FDOH is also a leader in piloting new models of service delivery, including a teledentistry pilot project. Finally, the FDOH takes a leadership role in integrating oral health into other state programs, such as chronic disease programs and school health programs. However, many barriers also face state health departments. Financial barriers prohibit the expansion of existing effective models as well as surveillance activities. Also, many states experience resistance related to changing licensure and scope of practice regulations. Overall, overcoming these barriers requires collaboration among many diverse stakeholders. In Florida, the FDOH works with other public health entities, academia, private foundations, communities, policy makers, industry, and organized dentistry to continue to make progress in oral health.

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 REFRAMING THE SYSTEM WORKING WITH STATE LEGISLATORS Peter C. Knudson, D.D.S., M.S. Utah State Senate When working with state legislators, it is important to remember that politics is very often a local issue as well as an art form. The United States has a representative government, and state legislators are often elected to serve a very wide constituency. For example, one district may include constituents ranging from farmers to aerospace engineers. For that reason, legislators need to be informed on a wide variety of issues, and they often are not equally well informed on everything. Getting to know your local legislators and sharing your concerns on a one-on-one basis is important for making your legislators aware of important issues. This does not necessarily guarantee success, but does get an issue into the proper channels and sets up a relationship for an indi- vidual to become a trusted resource when needed. Additionally, because legislators have to work on so many different issues, messages should be clear and distinct. For example, a single sheet with bullet points to highlight the issue is more valuable to a legislator than a large document; this will let the legislator know the key issues, and he or she will certainly know where to go for more information. The first key element of a successful lobbying effort is to have a presence where the legislation is being passed. This might mean having a presence in Washington, DC, for issues that need to be decided at the federal level or a presence at the state capital for state-level issues. In both of these cases, lobbyists may be this presence. The second element is that it takes financial resources to fight for an issue. For example, hiring lobbyists costs money, and one’s own time has value. Political action committees can help with this. Finally, there must be a very active grassroots level. People need to be work- ing all the time to keep an issue moving forward and in the spotlight. STATE GOVERNMENT Tricia Leddy Rhode Island Department of Health State governments have multiple roles in improving access to oral health care services. As payors, states not only administer Medicaid but are also large employers (of state employees). State oral health profession- als have the opportunity to advocate for benefit changes for Medicaid and state employees. As regulators, states have several opportunities to affect oral health policy. States can change professional regulations to improve

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 THE U.S. ORAL HEALTH WORKFORCE access. States also regulate health facilities and can change regulatory requirements. In some states, requests by health care facilities to expand, merge, or make other changes are regulated, thus there is the opportunity to add conditions such as providing access to oral health services. Rhode Island often puts conditions on health facility expansion requests to pro- vide a certain amount of primary care to the uninsured. Why not consider requesting the state consider a condition to the establishment of a free den- tal clinic or the expansion of an existing clinic to include dental services, in coordination with a hospital expansion? Finally, states are involved in public health education, health promotion, professional loan repayment, and many other programs that may be leveraged to improve access to oral health services. Since state budgets are especially tight right now, and oral health care does not easily allow for budget rebalancing as can be done in medical care (e.g., reinvestment of emergency room savings from reduced utilization into primary care), states particularly need to consider strategies to expand oral health access that do not require new money. Through the Medicaid program in Rhode Island, the state has provided leadership by moving from a payor role to a purchaser role. In the early 1990s, the state changed the Medicaid program for families to a Medicaid managed care program. At the beginning, there was poor access to dental care services, largely due to resistance from the dental community toward managed care. In 2005, Rhode Island implemented RIte Smiles for chil- dren, moving from being merely a payor to being a purchaser by purchas- ing benefits through a dental benefit manager, which in turn increased fee-for-service rates for primary care dental services. The state was able to specify oral health performance measures and access standards. RIte Smiles resulted in a five-fold increase in preventive and treatment visits and a 10-fold increase in dentists’ participation without any investment of new funds. The state received technical assistance from the Center for Health Care Strategies, funded by the Robert Wood Johnson Foundation, regarding how to create an effective purchasing strategy for children’s oral health services. This led to a two-fold strategy. The first was to add a utili- zation review process for approval of orthodontia requests, using national standards. Savings were reinvested into RIte Smiles, toward increasing primary dental care reimbursement rates. The second part of the strategy was to enroll all Medicaid-enrolled children under age 6 in the RIte Smiles dental benefit manager program, and thus improve their access to preven- tive dental services. This was predicted to result in immediate as well as future savings in dental treatment costs by preventing caries. Children do not “age out” of RIte Smiles. By 2009, 60,000 children under the age of 10 were enrolled in RIte Smiles. As a result, while the number of preventive and treatment visits has increased, the rate of high-cost procedures associ- ated with more complex oral health disease has decreased significantly. In

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 REFRAMING THE SYSTEM fact, savings from preventing the need for high-cost procedures have been reinvested in preventive services by increasing reimbursement rates as well as increasing utilization. Finally, Rhode Island has provided leadership in improving access to oral health care services by partnering with private foundations to provide capital investments toward self-sustaining programs. Using these funds, first the state established school-based clinics in underserved areas across the state. Second, Rhode Island increased capacity by funding new full-service dental clinics and expanding existing clinics in underserved areas. Third, the state increased the capacity of two existing dental residency programs. Fourth, the state established a dental assistant training program. This pro- gram uses federal job training funds to train mothers who are reaching their time limit on cash assistance to become dental assistants. States certainly have many opportunities to improve access to oral health care services. HEALTH POLICY Howard Bailit, D.M.D., Ph.D. Uniersity of Connecticut Problem Definition Bailit stated much of this meeting focused on using midlevel profes- sionals to address dental access disparities. The underlying assumption is a large increase in the supply of a lower-cost practitioner will solve the access problem. This assumption needs to be challenged. All things being equal, the size and composition of the health care workforce has little relationship with access disparities. This is because the basic problem in dentistry is the demand for care: underserved populations do not have the personal financial means to purchase services, and most of the poor do not qualify for public dental insurance (i.e., Medicaid). Even those covered have difficulty getting treat- ment because of low Medicaid reimbursement rates. Thus, just increasing the number of dentists or midlevel professionals will not solve the disparities problem. More professionals will not treat the poor; instead, they will locate in middle and upper income areas where they can make a living. Capacity of Dental System Questions exist about the chances states will increase demand by expanding the dental Medicaid program to include more of the poor and by making reimbursement rates more competitive. Currently, states do not have the resources to significantly increase their investment in the dental

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4 THE U.S. ORAL HEALTH WORKFORCE Medicaid program. Also, dentistry is not well positioned to compete with other more politically powerful segments of the health care system (e.g., hospitals, long-term care facilities) lobbying state legislatures for increased Medicaid funding. There is some chance the federal government may take more financial responsibility for dental care for low-income children. The recent passage of an expanded CHIP program is a step in the right direc- tion. Assuming that adequate funds for poor children are forthcoming, there may be several options for increasing the supply of services to treat several million more children. One strategy is to increase the use of midlevel professionals. In this regard, 1 year from now perhaps three states will legalize the profession of dental therapy with the support of state dental associations. This being the case, the debate about a new type of oral health professional needs to end, even though this is a very politically charged issue in many segments of the dental education and practice communities. Instead of debate, the leader- ship of organized dentistry and other stakeholder groups need to come together and address the many unresolved issues about the training, super- vision, and regulation of dental therapists. The chaos of 50 states making these decisions separately must be avoided. Although dental therapists will become part of the dental workforce, it will take 10 years or more to pro- duce the numbers needed to significantly affect the child access problem. Certainly, the United States cannot wait 10 years to address this issue. There is strong evidence that the existing system has the capacity to meet the needs of several million more low-income children. First, most dental practices have large numbers of essentially healthy patients who only need maintenance services. Many of these patients can be seen at intervals longer than the conventional 6 months with minimal health risk. By changing visit intervals, practices can treat more new patients. Second, the productivity of dentists can be substantially increased with the more effective use of dental hygienists, dental assistants, and administrative staff. Greater productivity means that more patients can be treated per unit of time. Third, there are opportunities to develop school-based delivery sys- tems for low-income children who, for a variety of reasons, have difficulty accessing the current system of care. In Connecticut, dental hygienist-led teams employed by federally qualified health centers screen and provide preventive services to school children using portable equipment. For the 30 to 40 percent of children who require restorative and other dentist services, most are treated by dentists in schools using portable equipment. Only a small percentage of children have behavioral or other problems that require treatment in a fully equipped dental operatory. Finally, the efficiency of the dental safety net system can be improved with the more effective use of con- ventional allied dental health personnel (e.g., dental assistants). The bottom line is that the current dental delivery system has the capacity to care for

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 REFRAMING THE SYSTEM several million more children from low-income families if the Medicaid and CHIP programs are adequately funded. Underserved populations do not have to wait until dental therapists are available. Workforce Planning and Education A rapid expansion of the dentist workforce is now underway. Since 2000, 12 new dental schools have started or are in the planning stage, and many existing schools are expanding enrollment. Bailit expressed concern for the large numbers of new dentists entering the system at the same time as hundreds or thousands of dental therapists. While the supply of services is expanding, the rate of increase in demand is slowing due to continued improvements in the population’s overall oral health. This country needs to develop a long-range plan for the dental workforce. Several European countries have addressed this issue and have decided to reduce the number of dentists trained and to upgrade dental education, so dentists are better prepared to care for more dentally and medically complicated patients. While this solution may not make sense for the United States, this issue needs to be addressed. DENTAL EDUCATION Frank Catalanotto, D.M.D. Uniersity of Florida College of Dentistry The existing dental education system is, in part, to blame for many of the problems faced in improving access to oral health services including the lack of practitioner participation in the Medicaid program, the opposition of organized dentistry to new workforce models (except their own), and the restrictive dental practice acts of many state boards of dentistry. Change can be very difficult for dental educators as well, but change is necessary to solve current problems. Academic excellence must be at the forefront of developing and evaluating new models of education and models of care delivery, and attempts to block demonstration projects in academic dental institutions should be regarded as a breach of academic freedom. First, much more collaboration and integration is needed. The dental health care education system and the patient care system need to be inte- grated at all levels of the oral health team and within the overall health care system. Interdisciplinary teams are necessary to address the health care needs of the public, including its oral health. However, if we expect oral health professionals to work in a more collaborative manner with each other and other health professionals, they must be educated and trained together. New

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 THE U.S. ORAL HEALTH WORKFORCE academic dental institutions should be built in collaboration with medical schools and academic health centers to foster interdisciplinary education. Second, clinical education needs to be improved. Better education and training is needed regarding the care of special populations including chil- dren, patients with special care needs, older adults, and other vulnerable populations. More attention is also needed on the cognitive or behavioral skills of dentists, including more emphasis on ethics, professionalism, cul- tural competency, and the value of evidence-based approaches to oral disease management. Third, more attention is needed regarding the types of students recruited for careers in oral health. There is growing evidence that recruiting stu- dents from diverse racial, ethnic, and socioeconomic backgrounds produces professionals who pay special attention to those populations. Catalanotto stated that his own unpublished research shows that while only 5 percent of American families have incomes over $185,000 annually, more than one- third of first-year dental students at the University of Florida come from such families. These students may not be able to relate to the patients who are in the most need of care. Finally, academic dental institutions have expertise in many areas and should provide that expertise wherever possible. For example, the new CHIP legislation calls for an evaluation of the oral health status of children. Departments of public health and epidemiology within dental schools can provide expertise on how to design surveys. Overall, all members of the dental team need to be integrated into the health care system, involving the need for difficult but necessary changes in the education of all types of dental professionals. ADVOCACY Advocacy and Policy Makers Bruce Lesley First Focus Changing public policy requires both knowledge and will. For example, the U.S. surgeon general’s report on oral health provided a lot of information about tooth decay, noninsurance, and the unmet oral health needs of chil- dren, but many policy makers remain unaware of these facts (HHS, 2000). In addition, oral health advocates need to take advantage of windows of oppor- tunity to make policy change, such as the tragic death of Deamonte Driver that made headlines across the country and paved the way for the passage of CHIP legislation. One factor that stalls efforts to create new policies dur- ing these windows of opportunity is dissention among professional groups.

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 REFRAMING THE SYSTEM When stakeholders come together, it is much easier to create legislation around shared public policy interests. Stakeholders need to stop complaining about the current system and work together to improve it. Advocates need to continue to work to create a system of care for all children through both public and private strategies. The passage of CHIP is significant for several reasons. First, the legislation legally requires states to provide dental coverage and services for CHIP beneficiaries. Second, it allows states to provide dental wraparound coverage for privately insured children who lack dental coverage. (Previously, children had to drop their medical coverage to get CHIP benefits.) Third, states must report on dental performance. In the next round of expansions, more effort is needed to assure dental capacity in the community health centers that currently do not provide dental services. In addition, more can be done to provide dental screenings in schools, just as is routinely done for vision and hearing screenings. Other health professions need to be engaged in oral health care; for example, pedia- tricians should be including oral health as a part of their prevention and dis- ease management strategies. Finally, more investment and attention is needed to increase the cultural competence and diversity of the dental workforce. Advocacy and Coalition Building Michael Scandrett Halleland Health Consulting—Minnesota Safety Net Coalition The Minnesota Safety Net Coalition (MSNC) is a group of safety net providers including community clinics and health centers, dental clinics, safety net hospitals, home- and community-based providers, and advo- cates who share a common interest in serving low-income, uninsured, and disadvantaged patients who face multiple barriers to accessing health care services. Three years ago, the MSNC identified dental access as its top issue. Mental health clinics found dental health was the second highest concern among patients with serious and persistent mental illness. The safety net hospitals noted dramatic numbers of people with serious dental problems coming to emergency rooms and receiving stopgap treatments (e.g., pain medication and referral), only to return when the pain medication runs out because there is nowhere to go with the referral. The home- and community-based providers noted that homebound patients often have no one willing or able to come see them in the home setting, and they face multiple challenges trying to leave the home to receive treatment. As a result, the MSNC formed an oral health committee sponsored by the United Way. One of the first strategies to arise was the concept of a new type of advanced professional, called the oral health practitioner (OHP). When a group of people have a wide variety of perspectives on an issue,

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8 THE U.S. ORAL HEALTH WORKFORCE they are often able to come together and reach agreement if they are truly willing to listen to each other, learn about each other’s perspective, and accommodate legitimate concerns. However, in the case of the OHP, some stakeholders were unwilling to sit down and discuss areas of disagreement. As a result, the MSNC made this issue a top priority and invested in lobby- ing and staffing to advance this as an access issue, proposing a bill for the new oral health practitioner. Several professionals in the community admit- ted they had been subject to threats and intimidation for their support of the bill. Some stakeholders presented legislators with personal opinion in opposition of the bill, disregarding a wealth of evidence, and the MSNC spent much of its time explaining to legislators how this information was inaccurate. This type of dissension does not allow for fuller discussion of the issues that might lead to conditions amenable to all stakeholders. No single strategy is going to solve the problems of access to oral health care services. For example, aside from Medicaid and the traditional systems of care, Minnesota uses multiple strategies including critical access payments, collaboration with dental hygienists, expanded functions for dental assistants, legislative changes to include community health workers in dental care, and grants and loan forgiveness programs. To solve these problems, stakeholders need to come together, through coalitions or other means, so legitimate concerns can be heard and broad support for solutions to challenges can be created. MEDIA Mary Otto Street Sense Poverty, homelessness, health care, housing, and social issues are usu- ally not high-profile stories. Some people will say that is because poor people don’t read the newspaper, and the issues aren’t glamorous. How- ever, real stories about real people combined with careful journalism can help address the larger social issues that surround these people’s lives and struggles. Such is the case of Deamonte Driver. Laurie Norris from the Public Justice Center in Baltimore contacted Otto, then a staff writer with the Washington Post, about a homeless mother in Maryland, Alyce Driver, with five sons. Alyce Driver had held a series of jobs, none of which provided health insurance. When they finally qualified for Medicaid, they were challenged to find a dentist to treat them. Ms. Norris and her staff made dozens of calls to find someone to care for one of Alyce Driver’s sons. In the meantime, another one of her sons, Deamonte, fell ill. In January 2007, Deamonte came home from school with a progressively worsening headache, eventually found to be related to

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 REFRAMING THE SYSTEM sinusitis and a dental abscess. Deamonte’s condition declined, necessitating emergency brain surgery. The nidus of the infection, the infected tooth, was finally removed and Deamonte began his long journey to recovery. However, in February 2007, Deamonte suddenly succumbed to the brain infection that had never totally cleared. The story of Deamonte Driver’s life and death, as well as the many stories to follow, fostered a personalization of the barriers faced by poor families including systemic problems of the Medicaid system as well as personal obstacles such as transportation, transience, and erratic phone and mail service—things that do not challenge middle-class families. Low- income parents, just like other parents, often lack awareness about the importance of dental care, but this is more significant when a child does not get routine oral health visits. Also, this is not just an urban issue. In rural areas, a clinic might serve children living 2 or 3 hours away because no other practitioner will serve Medicaid children. It is also not just a Maryland problem—while Maryland’s Medicaid reimbursement rates were among the lowest in the nation, Congressional hearings revealed similar challenges exist across the United States. Federal lawmakers seized this window of opportunity to pass the CHIP legislation. In addition, Maryland’s governor ordered an examination of the entire state’s Medicaid system and in spite of budget challenges, implemented the first phase of an effort to increase reimbursement rates and increase pro- vider participation in the Medicaid program. Additional funding was allotted to support clinics and redesign the infrastructure of the Medicaid program. In conclusion, the media can use personal stories to initiate and sus- tain attention to an issue like oral health. This can only be done with the participation of advocates, professionals, and others who give their time to explain the issues to the media. Stories open people’s eyes, and it is up to the media to continue to cover these stories and help the public understand the complexity of these issues. REACTION AND DISCUSSION Moderator: Len Finocchio, Dr.P.H. California HealthCare Foundation Moderator: Elizabeth Mertz, M.A. Center for the Health Professions, Uniersity of California, San Francisco An open discussion followed the panelists’ presentations. Audience participants were able to give comments and ask questions of the panelists. The following sections summarize the discussion session.

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0 THE U.S. ORAL HEALTH WORKFORCE Changing Regulations One participant asked about establishing reimbursement to physicians for early childhood preventive procedures in the minority of states that do not already do so. Davis said that while the American Academy of Pediatrics has encouraged this, it is a state-based Medicaid decision and so would have to occur on a state-by-state basis. Cober added that state agencies can be helpful, such as by securing grant funding to provide edu- cation and training for nondental professionals. Leddy noted that not all dentists agree with allowing nondental professionals to deliver these types of services. Several participants asked about making changes to the EPSDT pro- gram. In response to a question about requiring physicians to provide these dental services, Davis said it would require a legislative change and while there have been some discussions, there is no official action yet. In a point of clarification, Davis noted that regulations do allow for these services to be provided by other unspecified types of licensed practitioners, which CMS has determined allows for the direct reimbursement to dental hygienists in states where their license allows them to practice in that manner. Several participants commented on the challenges of reimbursing oral health professionals aside from dentists. Brand and Davis agreed legislative change is often needed to give this authority. Engaging Stakeholders One participant suggested considering collaboration with nontraditional partners. Cober agreed collaboration with multiple partners is essential, not- ing Florida’s oral health coalition involves over 300 different individuals and organizations with a range of backgrounds. Leddy added as public servants, state workers act on behalf of citizens, and so it is much easier to take action when there is broad consensus as well as a champion. Brand agreed, noting stakeholders from the grassroots level and advocacy groups are often very effective in acting as the face of issues. She said partners who don’t neces- sarily benefit directly from proposals can often present the most compelling argument. Mertz suggested partnering with nontraditional advocates such as those working on childhood obesity issues who might have a shared interest in the relationship between sugar products and obesity and dental disease. For example, she noted the role of warnings on tobacco products to help reduce the rate of smoking. Lesley commented on the intense opposition by industry to these types of preventive measures. Other participants recognized the importance and efforts of multiple dental associations such as the American Association of Public Health Dentistry, the Association of State and Territorial Dental Directors, and

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 REFRAMING THE SYSTEM the American Association of Community Dental Programs in working together at the state, local, and national levels to improve access and share best practices. Another participant added these associations along with the American Public Health Association should take the lead in addressing issues surrounding access to oral health for underserved populations. Another participant commented on the need for all stakeholders to rec- ognize shared and differing challenges, that they have all failed collectively, and that everyone needs to come together to solve these problems that have not changed in many years of discussion. Another participant noted many oral health professionals hesitate to become more engaged due to fears of retribution by other professionals or even their own associations. One participant specifically thanked Mary Otto for treating the Driver family with respect and compassion and for telling Deamonte’s story in such a compelling way that the country and world could not ignore the problem. She encouraged all participants to continue their passion and commitment to keep working in collaboration and to keep extending the circle of people involved in creating solutions. Lesley agreed Otto’s coverage was crucial to creating an opportunity for the nation to come together. Recognizing Public Health Participants commented on the importance of the role of public health dentistry. One participant who referenced Brand agreed, adding public health dentistry has been significantly underresourced. Others partici- pants said the dental public health infrastructure needs to be strengthened and public health dentists need to become even more engaged in national debates. Another participant remarked public health professionals have the competencies for data collection and assessment, but fewer and fewer of these professionals are working in government. The participant added con- cerns about who will be making policy decisions around issues that require these types of skills. Finally, the participant said public health is a common theme that can bring many types of health professionals together. Targeting Underserved Areas One participant noted the decreasing numbers of National Health Service Corps (NHSC) scholarships and loan repayment programs for dentists to serve in HPSAs, stating the government should prioritize these types of programs for oral health professionals. The participant commented on other possible strategies for targeting oral health in underserved areas by financing and paying for services rendered by dental hygienists inde- pendently from dentists as well as the use of dental residents to serve in

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 THE U.S. ORAL HEALTH WORKFORCE community health centers as part of their training. Brand said the HPSA definition needs to be revisited, but efforts to do so in the past have not yielded much success. She added HRSA is making efforts to increase NHSC placements, but noted these types of programs can take several years to have any effect because of the length of time to train some of these profes- sionals (in the case of scholarships). Brand added limited resources can challenge the administration and expansion of these programs (as well as dental and public health residences). A participant added dental placement and career guidance might be better strategies to getting dentists into under- served areas, and those funds for loan forgiveness and scholarship programs could be better used in other ways. One participant referenced the Healthy Kids program in Michigan in which dental hygienists and dental assistants are allowed to perform expanded duties, and participants in the Delta Dental Plan are automati- cally eligible to treat underserved patients. The participant attributed some of the success of the program to the effective use of a state-based lobbyist and annual legislative visits at the state and national levels, but recognized the challenge of budgetary limitations. Creating National Goals A participant said a national conceptual framework is needed to link four factors: financing, workforce, partnerships, and education. The partici- pant asserted without a national set of goals, many people will be working on multiple little projects without making any major strides. Brand added a fifth consideration: she said there is no major national organization to speak for people with dental disease as there is for other diseases such as diabetes (i.e., the American Diabetes Association). She added these types of organizations are enormously strong and effective, especially at the grass- roots level. She said there needs to be a movement in gaining parity for oral health just as others are working for parity in mental health. Cober said in Florida, that void was filled by creating the statewide oral health coali- tion. She said this coalition has been effective in bringing together those additional needed voices. Other participants commented on the need for federal agencies to do more through their oversight capacity to promote oral health strategies and the need for national leaders to foster academic curiosity. Training and Practice Patterns In response to a comment about the need for significant and innova- tive efforts to train large numbers of students from various ethnic com- munities, Brand noted a lack of federal resources for many of these types

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 REFRAMING THE SYSTEM of innovations and that more recognition is needed that these challenges require investment over time. Another participant commented on the need for improving the quality of dental education and considering creating an oral physician. One participant clarified dental hygiene no longer has any 2-year programs. Another participant advocated for raising all dental hygiene programs to the level of a bachelor’s degree and the need to create more career ladders, especially as new types of practitioners evolve. Several questions arose about the effect of changing demographics on career patterns. Regarding a question about the impact of dual-career marriages on dentists’ choice of location, Brand said more data is needed regarding driving factors in career choices. In response to a question about the effect of the increasing number of female dentists, Brand reflected on the presentation of a previous speaker indicating the practice patterns seem to show that male dentists may work more hours in the beginning of their careers while women work more hours later in their careers. Regarding concerns about the changing practice preferences of dental and medical students (i.e., decreased willingness to work long hours), Brand said this lifestyle change is common to all professions, including nonhealth professions. One participant commented private practice patterns will not change to become more efficient because dentists like the traditional slow pace of private practice. Another participant stated the nation cannot wait for the productivity of private practice dentistry to change. A participant stated all models of care should be tested and evaluated to determine the most effective ways to improve the delivery of and access to oral health care services.

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