5

A New Oral Health Initiative

The U.S. Department of Health and Human Service’s (HHS’) commitment to improving the oral health of the nation has fluctuated; while there have been notable successes, these efforts have not led to oral health parity in health care overall. Substantial inequities remain across population subgroups, and many Americans continue to suffer from avoidable and treatable oral diseases. The expressed intent of the surgeon general’s report Oral Health in America was “to alert Americans to the full meaning of oral health and its importance in relation to general health and well-being” (HHS, 2000). Now, more than a decade later, scientific investments demonstrate significant dividends in some areas and some progress in children’s oral health has been made; yet many of the concerns raised in that report remain (Mertz and Mouradian, 2009; Mouradian et al., 2009; Slayton and Slavkin, 2009).

LEARNING FROM THE PAST

Through extensive research, testimony, and their own professional experiences, the members of the Institute of Medicine (IOM) Committee on an Oral Health Initiative considered why prioritization of oral health continues to be a challenge in HHS. In any initiative to improve oral health and oral health care, HHS’ challenge will be to marshal its resources in a way that produces a significant impact in the lives of people all across the country. Given that HHS’ resources are limited, the scope of the challenge is substantial, and many solutions will require the involvement of multiple



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5 A New Oral Health Initiative The U.S. Department of Health and Human Service’s (HHS’) commit- ment to improving the oral health of the nation has fluctuated; while there have been notable successes, these efforts have not led to oral health par- ity in health care overall. Substantial inequities remain across population subgroups, and many Americans continue to suffer from avoidable and treatable oral diseases. The expressed intent of the surgeon general’s report Oral Health in America was “to alert Americans to the full meaning of oral health and its importance in relation to general health and well-being” (HHS, 2000). Now, more than a decade later, scientific investments dem- onstrate significant dividends in some areas and some progress in children’s oral health has been made; yet many of the concerns raised in that report remain (Mertz and Mouradian, 2009; Mouradian et al., 2009; Slayton and Slavkin, 2009). LEARNING FROM THE PAST Through extensive research, testimony, and their own professional experiences, the members of the Institute of Medicine (IOM) Committee on an Oral Health Initiative considered why prioritization of oral health continues to be a challenge in HHS. In any initiative to improve oral health and oral health care, HHS’ challenge will be to marshal its resources in a way that produces a significant impact in the lives of people all across the country. Given that HHS’ resources are limited, the scope of the challenge is substantial, and many solutions will require the involvement of multiple 207

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208 ADVANCING ORAL HEALTH IN AMERICA stakeholders, one of the most important roles HHS can play is in providing leadership and direction for the rest of the country. The 2000 surgeon general’s report (HHS, 2000) presented the state of the science in oral health, called attention to the oral health care challenge facing the country, and outlined a framework for future action. While the report is still widely discussed today, it did not lead to a direct and immedi- ate change in the government’s approach to oral health. This disappointing outcome may have been due to broader environmental factors, including grave and immediate national crises (e.g., 9/11, Hurricane Katrina); changes in the economy that affect state and federal budgets (e.g., recessions); com- peting health policy priorities (e.g., obesity); a tendency to blame individual behaviors alone for poor oral health; a lack of political will; or simply the long-standing failure to recognize oral health as an integral part of overall health. But certainly part of the explanation lies in “gaps in leadership and the failure to unite a critical mass of key stakeholders with sufficient common interests, political will, and resources to effect fundamental pol- icy change” (Crall, 2009). Within HHS, changes in administrations (with concomitant changes in priorities), workforce turnover (including agency administrators), lack of oral health “champions,” insufficient funding and staffing, and the lack of oral health parity may all have contributed to the disappointing results. THE NEW ORAL HEALTH INITIATIVE As was discussed in Chapter 1, this committee was challenged by a statement of task that called for them to devise a “potential” oral health initiative, and then the subsequent announcement of the Oral Health Initia- tive 2010 (OHI 2010). The committee was mindful of the existence of the OHI 2010 but did not let its existence limit its considerations of what such an initiative should be. Therefore, in the rest of this chapter, the commit- tee outlines seven recommendations that as a whole comprise what will be referred to as the new Oral Health Initiative (NOHI) (to distinguish it from and build upon the current initiative). In considering a potential HHS oral health initiative, the committee developed a set of organizing principles (see Box 5-1) based on areas in greatest need of attention as well as approaches that have the most potential for creating improvements. It will be HHS’ responsibility to adapt the current structure of the OHI 2010 to these prin- ciples and the recommendations that follow. The committee concluded that these principles will help move the na- tion toward achieving the goals and objectives set by Healthy People 2020, which represents the best long-term set of benchmarks for judging the suc- cess of the NOHI. Healthy People 2020 is an existing and well-accepted set of benchmarks for the country developed by a strong collaboration of

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209 A NEW ORAL HEALTH INITIATIVE B OX 5-1 Organizing Principles for a New Oral Health Initiative  1. Establish high-level accountability.  2. Emphasize disease prevention and oral health promotion.  3. Improve oral health literacy and cultural competence.  4. Reduce oral health disparities.  5. Explore new models for payment and delivery of care.  6. Enhance the role of nondental health care professionals.  7. Expand oral health research, and improve data collection.  8. Promote collaboration among private and public stakeholders.  9. Measure progress toward short-term and long-term goals and objectives. 10. Advance the goals and objectives of Healthy People 2020. partners. The committee suggests that creating a new set of long-term goals would only contribute to the redundancy and fragmentation that is often criticized regarding government programming. In essence, attainment of Healthy People 2020 goals and objectives is the continuing mission of the NOHI. The committee further notes that this approach should not be lim- ited to the goals and objectives of the oral health section, but it also should embrace the goals and objectives of the health communication and health information technology section of Healthy People 2020. Building upon Healthy People gives the NOHI a framework for sus- tainability as well as the ability to change goals and objectives depending upon achievements in improving oral health. More importantly, as better measures of quality in oral health are developed, more sophisticated goals can be set. The committee also notes that shorter-term and intermediate goals and objectives will also be needed along the way toward these larger goals. Establishing High-Level Accountability All Americans, especially those from vulnerable and underserved popu- lations, are at risk of suffering compromised health. This is particularly important because HHS describes itself as “the United States government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves” (HHS, 2010a). The committee concluded that previous HHS efforts to improve oral

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210 ADVANCING ORAL HEALTH IN AMERICA health have largely suffered from lack of high-level accountability, a lack of coordination among HHS agencies, a lack of resources, and a lack of sustained interest. Considering the impact of oral diseases and disorders on the nation, its relevance to every American, and the importance of strong, accountable leadership, the committee recommends: RECOMMENDATION 1: The secretary of HHS should give the leader(s) of the new Oral Health Initiative (NOHI) the authority and resources needed to successfully integrate oral health into the plan- ning, programming, policies, and research that occur across all HHS programs and agencies: • Each agency within HHS that has a role in oral health should provide an annual plan for how it will integrate oral health into existing programs within the first year. • Each agency should identify specific opportunities for public- private partnerships and collaborating with other agencies inside and outside HHS. • The leader(s) of the NOHI should coordinate, review, and imple- ment these plans. • The leaders(s) of the NOHI should incorporate patient and con- sumer input into the design and implementation of the NOHI. The identification of specific leadership for the NOHI would create a robust level of accountability. Because there was not enough evidence to determine exactly who the leader(s) of the NOHI should be, the committee concluded that the secretary should ultimately determine the leader of the NOHI; presumably this could be the current co-leads, the head of the Oral Health Coordinating Committee (OHCC), a new office or officer dedicated to oral health, or another person who is given distinct authority. In any case, as discussed earlier, lack of strong and consistent leadership, insuffi- cient funding, and inadequate staffing all contributed to the ineffectiveness of previous efforts. Therefore, the committee recommends the named leader be given enough authority and resources to carry out his or her duties. If this effort is to be led by the OHCC, then clearly financial support will be needed where it currently has none. Toward the goal of fully integrating oral health into overall health, instead of merely listing existing or planned oral health activities, the com- mittee recommends that each relevant operating and staff division provide clear directions and goals for integrating oral health into all of its relevant programs within the first year of the NOHI. Aside from their individual abilities, each division should look for clear opportunities to partner with other entities, both within and outside of HHS. The committee urges that these individual plans focus on the issues laid out in the framework for the

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211 A NEW ORAL HEALTH INITIATIVE NOHI and include measurable objectives. These objectives could focus on shorter-term or intermediate measures of departmental performance such as implementation of new programs and collaborations or demonstrated impact on oral health status and access. The leader(s) of the NOHI would be responsible for oversight of all of these plans, including looking for overarching areas for collaboration and learning both within HHS and with external partners. Finally, in concert with the IOM definition of quality,1 which includes patient-centeredness as a goal, the committee recommends the NOHI pur- sue a focus on patient-centered (and community-centered) care and there- fore seek ways to ensure that the patient’s and consumer’s perspectives (including those of private-sector and other public-sector stakeholders) is recognized and appreciated in future oral health planning. Focusing on Prevention Among the most important contributions that HHS can make to im- prove oral health is to promote the use of regimens and services that have been shown to promote oral health, prevent oral diseases, and help manage these diseases. Too often, oral health care focuses more intently on treating disease once it has already become manifest. A focus on prevention may help to reduce the overall need for treatment, reduce costs, and improve the capacity of the system to care for those in need. HHS plays a key role in promoting the adoption of evidence-based pre- ventive oral health services, including those provided at the national, state, community, and individual levels. For example, as discussed in Chapter 4, the U.S. Preventive Services Task Force assesses the evidence about clinical preventive services while the Task Force on Community Preventive Services does the same for community-based preventive services. In addition to its role in assessing preventive services, HHS and the federal government as a whole directly provide (or oversee the provision of) a significant amount of oral health care. The committee concluded that (1) preventive services and counsel- ing have a strong evidence base for promoting oral health and preventing disease; and (2) HHS is a key provider of oral health care, especially for vulnerable and underserved populations through the safety net. Therefore, the committee recommends: RECOMMENDATION 2: All relevant HHS agencies should promote and monitor the use of evidence-based preventive services in oral health 1 In 2001, the IOM defined six dimensions of quality: safety, effectiveness, patient- centeredness, timeliness, efficiency, and equity (IOM, 2001).

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212 ADVANCING ORAL HEALTH IN AMERICA (both clinical and community based) and counseling across the life span by • Consulting with the U.S. Preventive Services Task Force and the Task Force on Community Preventive Services to give priority to evidentiary reviews of preventive services in oral health; • Ensuring that HHS-administered health care systems (e.g., Fed- erally Qualified Health Centers, Indian Health Service) provide recommended preventive services and counseling to improve oral health; • Providing guidance and assistance to state and local health systems to implement these same approaches; and • Communicating with other federally administered health care sys- tems to share best practices. This recommendation is in alignment with the HHS Strategic Plan for FY 2010–2015 that promotes “the incorporation of oral healthcare services and oral disease prevention into primary healthcare delivery sites” and “policies to integrate oral health into primary care, including preven- tion and improved health literacy” (HHS, 2010c). Overall, the plan states “Improved availability of oral health services, including disease prevention, treatment, and health promotion and education, should be promoted for poor and underserved populations as well as for the population at large.” A first step for the U.S. Preventive Services Task Force and the Task Force on Community Preventive Services would be to reexamine modali- ties that have been looked at previously but had insufficient evidence (see Chapter 4). The committee encourages the provision of preventive services in HHS-administered health care systems by any and all health care pro- fessionals who are competent to do so; for example, physicians, nurses, and others could be involved either through direct provision of care (e.g., fluoride varnish) or through examination, risk assessment, and appropri- ate referrals as needed. Assistance to state and local health systems could include both financial assistance and technical assistance, through the shar- ing of best practices. Consideration will also be needed for the adequacy of and support needed for the public health infrastructure to support these activities—both at the federal and the state level. HRSA’s regional offices might be one option to provide technical assistance at the state and local levels. The Centers for Disease Control and Prevention’s (CDC’s) grants to states for supporting public health infrastructure also could help encourage these activities.

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213 A NEW ORAL HEALTH INITIATIVE Improving Oral Health Literacy Overall, evidence suggests that the general oral health literacy of both individuals and all types of health care professionals is poor, especially in understanding the causes and prevention of oral diseases and how to communicate about these issues. For example, despite decades of evidence regarding the infectious nature of dental caries and the value of fluoride in preventing dental caries, both professional and patient knowledge regarding these issues remains lacking. In addition, poor oral health literacy contrib- utes to poor access because individuals may not understand the importance of oral health care or their options for accessing such care. The committee concluded that the oral health literacy of individuals, communities, and all types of health care providers remains low. This includes knowing how to prevent and manage oral diseases, the impact of poor oral health, how to navigate the oral health care system, and best techniques in patient–provider communication. Therefore, the committee recommends: RECOMMENDATION 3: All relevant HHS agencies should undertake oral health literacy and education efforts aimed at individuals, com- munities, and health care professionals. These efforts should include, but not be limited to, • Community-wide public education on the causes and implications of oral diseases and the effectiveness of preventive interventions; o Focus areas should include ■ The infectious nature of dental caries, ■ The effectiveness of fluorides and sealants, ■ The role of diet and nutrition in oral health, and ■ How oral diseases affect other health conditions. • Community-wide guidance on how to access oral health care; and o Focus areas should include using and promoting websites such as the National Oral Health Clearinghouse and www.health care.gov. • Professional education on best practices in patient–provider com- munication skills that result in improved oral health behaviors. o Focus areas should include how to communicate to an increas- ingly diverse population about prevention of oral cancers, dental caries, and periodontal disease. As described in relation to the previous recommendation, this current recommendation aligns with the HHS Strategic Plan for FY 2010–2015 that calls for improvements in oral health literacy and oral health promo- tion and education (HHS, 2010c). In her presentation to this commit-

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214 ADVANCING ORAL HEALTH IN AMERICA tee, Dr. Marcia Brand, deputy administrator of the Health Resources and Services Administration (HRSA), noted that as part of the statement of task, HHS was interested in learning more about how to increase public awareness and communicate specific messages of the relationship between good oral health and good overall health (Brand, 2010). She also noted that HRSA was interested in the oral health literacy of all types of health care professionals, including what types of messages could be sent to them regarding prevention of oral diseases (and how to communicate these mes- sages). The committee did not find enough evidence specifically in the oral health literacy and behavioral change literature to recommend exact strate- gies for delivering needed messages; therefore, it has given examples within the recommendation of the areas that have the most evidence supporting the need for outreach in these areas. (Research in oral health behavioral change will be discussed later in these recommendations.) The committee intends the highlighting of these areas to provide direction for HHS. In ad- dition, the CDC might consider targeting these areas if the CDC oral health campaign related to prevention authorized in the Affordable Care Act (see Chapter 4) is eventually funded. The committee fully supports the funding of this national campaign to promote awareness of oral health promotion and disease prevention. In addition, this type of campaign represents an- other opportunity where input from other public and private stakeholders would be valuable, especially in learning about successes and failures of other individual campaigns. Finally, the committee recognizes that any literacy and education efforts should be carried out in accordance with standards for culturally and linguistically appropriate services. Enhancing the Delivery of Oral Health Care To meet the oral health care needs of the U.S. population, several workforce changes are needed. Dental professionals need more training in community-based settings in order to learn more about caring for under- served and vulnerable populations. Nondental health care professionals (e.g., nurses, pharmacists, physician assistants, physicians) are often not prepared to provide basic oral health care. This may include being able to recognize disease, teaching patients about self-care, or providing basic preventive services. In addition, both dental and nondental health care professionals need better training in collaborative efforts, including the appropriate use of referrals in both directions, and more research will be needed to understand best approaches. For example, examinations of team- based care may need to consider how health information technology might be used, such as through the integration of medical and dental electronic records. The emergence of new types of dental professionals and the use of existing professionals in expanded roles, as discussed in previous chap-

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215 A NEW ORAL HEALTH INITIATIVE ters, has been contentious for decades. Other health care professions have expanded roles for existing professionals in high-risk situations, and these efforts have also been accompanied by political tension between profes- sions. While the evidence in this country on the quality of oral health care provided by health professionals who are not dentists is early and limited, without further research and evaluation, including a comparison of the quality of that care as compared to the care of dentists, better workforce models cannot be developed. Finally, particular attention is needed for underrepresented minority groups who often suffer from disparities in oral health. Health care professionals who are themselves from underrepre- sented minority groups often care for a larger proportion of patients from these populations. However, the racial and ethnic makeup of the dental professions has not changed markedly over time, and while programs such as bridge and pipeline programs have had some successes, newer models and methods of attracting a diverse student body need to be explored. The committee concluded that (1) nondental health care profession- als are well situated to play an increased role in oral health care, but they require improved education and training; (2) interprofessional, team-based care has the potential to improve care-coordination, patient outcomes, and produce cost-savings, yet dental and nondental health care professionals are largely not trained to work in this manner; (3) new dental professionals and existing professionals with expanded duties may have a role to play in expanding access to care; and (4) efforts to broaden the diversity of the oral health care workforce have not produced marked changes. While the regulation of health care professions occurs at the state level, HHS has a role to play in both the education and training of the health care workforce (as noted in Chapter 4) as well as the demonstration and testing of new innovative workforce models for specific needs (as noted in Chapter 3 and through elements of the Affordable Care Act and the HHS Strategic plan, both described in Chapter 4). These issues all require in- novative research and demonstration efforts in order to more fully develop the evidence base on their value and best use. Therefore, the committee recommends: RECOMMENDATION 4: HHS should invest in workforce innova- tions to improve oral health that focus on • Core competency development, education, and training, to allow for the use of all health care professionals in oral health care; • Interprofessional, team-based approaches to the prevention and treatment of oral diseases; • Best use of new and existing oral health care professionals; and • Increasing the diversity and improving the cultural competence of the workforce providing oral health care.

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216 ADVANCING ORAL HEALTH IN AMERICA This recommendation aligns with the HHS Strategic Plan for FY 2010– 2015. One of the five identified goals of the plan is “Strengthen the nation’s health and human service infrastructure and workforce” through objectives that address improving cultural competence and expanding care teams (including the use of new types of professionals). In fact, the plan has an explicit strategy for oral health: “Expand the primary oral health care team and promote models that incorporate new providers, expanded scope of existing providers, and utilization of medical providers to provide evidence- based oral health preventive services, where appropriate” (HHS, 2010c). In addition to the training and composition of the oral health work- force, more needs to be done to consider alternatives to how oral health care can be delivered and financed to improve availability and scope of oral health coverage and care. Chapter 3 gives an overview to the financing of oral health care. Dental coverage is strongly associated with receiving oral health care, yet many Americans, especially older adults, do not have this coverage. The separation of dental coverage from overall health care coverage reinforces the separation of oral health from overall health. The committee concluded that oral health care is so integral to the overall health of individuals and the population that financing of these services would ide- ally be part of every health plan. However, the committee also recognizes the current political and economic infeasibility of seeking to have all oral health services covered under health care plans. The committee found that not enough research has been done to deter- mine if alternative payment mechanisms might be more efficient to finance oral health care and pay for delivery of the most effective services in the most efficient manner, or to determine if the delivery of preventive services would result in long-term cost savings (which would have implications for the scope of coverage). Some consideration might be needed for how the current compensation system drives the delivery of oral health care. For example, like in general health care, fee-for-service payment structures of- ten reinforce the delivery of treatment services rather than preventive care. Like in general health care financing, exploration is likely needed for how alternative payment structures such as the bundling of payments and pay for performance might affect care delivery. Also like in the general health care system, incentives may be needed to encourage oral health care providers to work in underserved areas or with underserved populations, such as increased payments for Medicaid provid- ers or reimbursement for services performed by nondental health care pro- fessionals. Chapter 3 describes the delivery of oral health care services, yet also recognizes that distinct segments of the American public are not well served by the current system and that alternative solutions need to be ex- plored (as discussed in the previous recommendation). As more members of

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217 A NEW ORAL HEALTH INITIATIVE the overall health care workforce become competent and licensed to deliver care, research will be needed for how they will work and be reimbursed. In January 2010, the Advisory Committee on Training in Primary Care Medicine and Dentistry said, “CMS needs to work with primary care lead- ership organizations to develop strategies to redefine how to deliver and reimburse primary care (HHS, 2010b).” It added, CMS should pilot and evaluate reimbursement strategies that compensate for nontraditional approaches to care such as group visits, telephone and electronic communication, care management, and incorporation of non- traditional provider types (such as patient educators, patient navigators, and community health workers). They suggested that such approaches could both improve outcomes and contain costs. The committee concluded that (1) distinct segments of the U.S. popu- lation have challenges with accessing care in typical settings of care; (2) lack of dental coverage contributes to access problems; (3) newer financing mechanisms might help contain costs and improve health outcomes; and (4) new delivery models need to be explored to improve efficiency. Therefore, the committee recommends: RECOMMENDATION 5: CMS should explore new delivery and pay- ment models for Medicare, Medicaid, and CHIP to improve access, quality, and coverage of oral health care across the life span. The committee notes that one option for how CMS could explore some of these models is through the Center for Medicare and Medicaid Innova- tion (the “Innovation Center”), which was established within HHS under a provision of the Affordable Care Act of 2010. The Innovation Center is focused on achieving improvements in three areas: 1. Better care for people (improving patient care across inpatient and outpatient settings, and developing ways to make care safer, more patient-centered, more efficient, more effective, more timely, and more equitable); 2. Care coordination (developing new models for transprofessional col- laboration); and 3. Improved community care models (initiatives designed to improve the health of communities (e.g., obesity and heart disease) (Berwick, 2010). The Innovation Center will help to identify, support, and evaluate mod- els of care that improve the quality of care while also lowering costs. This includes demonstration projects on the effectiveness of team care and the impact of more coordinated payments (Carey, 2010; CMS, 2010b).

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218 ADVANCING ORAL HEALTH IN AMERICA As with the previous recommendations, this recommendation aligns with the HHS Strategic Plan for 2010–2015 for its focus on improving how care is delivered. In addition, the plan identifies an overarching goal to “transform health care,” including specific objectives to create new models for health delivery and payment that promote effective care and reduce costs (HHS, 2010c). Expanding Research Throughout the evidence-gathering process for this report, the commit- tee noted a significant lack of robust evidence related to many different as- pects of oral health care. While Chapter 2 highlighted significant oral health disparities between different populations, not enough is known about the best ways to decrease these disparities. Similarly, Chapter 2 describes the basics of health literacy practices and principles, including its relationship to disease management and behavioral change. The chapter highlights that although methods of preventing oral disease are well established, knowl- edge of these methods is still limited, both on the part of the public and even many professionals. In addition, not enough evidence yet exists to determine the best methods for changing behaviors in oral health specifi- cally. Chapter 3 notes that very little evidence exists for the quality of oral health services. Very few measures of quality exist for oral health, leading to little evidence not only about the quality of the services themselves but also about their ultimate relationship to long-term improvements in oral health. Quality assessment efforts in oral health lag far behind analagous efforts in medicine. Finally, in Chapter 4 the committee describes the role of many other federal agencies in the oral health care of a significant num- ber of Americans. The committee recognizes that these other agencies all have data collection systems and that consolidation of the data collected by these multiple sources would be useful in performing secondary research in oral health by many types of researchers. However, much effort would be needed to make all of these data usable. Based on the findings in all of these chapters, the committee concluded that a more robust evidence base in oral health is needed overall. The com- mittee concluded that efforts are needed most toward (1) generating new evidence on best practices; (2) improving the usefulness of existing data; and (3) evaluating the quality of oral health care (including outcomes). Therefore, the committee recommends: RECOMMENDATION 6: HHS should place a high priority on efforts to improve open, actionable, and timely information to advance science and improve oral health through research by

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219 A NEW ORAL HEALTH INITIATIVE Leveraging resources for research to promote a more robust evi- • dence base specific to oral health care, including, but not limited to, o oral health disparities, and o best practices in oral health care and oral health behavior change; Working across HHS agencies— in collaboration with other federal • departments (e.g., Department of Defense, Veterans Administra- tion) involved in the collection of oral health data—to integrate, standardize, and promote public availability of relevant databases; and Promoting the creation and implementation of new, useful, and • appropriate measures of quality oral health care practices, cost and efficiency, and oral health outcomes. In terms of “leveraging resources,” the committee supports the direc- tion of new funding toward research, but in recognizing that this is a time of limited resources, it emphasizes that HHS should prioritize oral health research when deciding upon distribution of existing resources. While the committee fully supports fundamental research that underpins oral health, again, in a time of limited (or diminishing) resources, the committee asserts that research in disparities, best practices, and behavioral change are areas that are especially lacking in evidence and could have a great impact on long-term goals. Research on oral health disparities is especially needed to understand best approaches to reducing those disparities. The research into best practices in oral health should be interpreted broadly because many areas of research are still needed related to individual procedures, oral health literacy, interprofesssional approaches, and many other areas, all of which contribute to oral health overall. In addition, part of this research will require consideration of how to transfer oral health research results into use by appropriate user groups. As previously noted, the committee sees that in addition to the need for new primary research, many databases already exist in multiple places, but they are not currently structured in a manner that allows for full integration of these data. Examples of data sets that include oral health information include the Medical Expenditure Panel Survey, the National Health and Nutrition Examination Survey, the Pregnancy Risk Assessment Monitor- ing System, and the National Health Interview Survey, among many oth- ers. Nearly all of the data sets are supported, at least in part, by different branches of the federal government. Some of these, however, do not have recent data. The primary purpose here would be for secondary research on the vast amounts of existing data that are not being used efficiently. In addition to

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220 ADVANCING ORAL HEALTH IN AMERICA the publicly available data sets, there are many other data sets that exist and contain useful data. While the committee recognizes that some data may not be able to be shared (e.g., sensitive data such as in cases of mili- tary databases), these data, whenever possible, should be made available to all researchers. For example, HHS’ Community Health Data Initiative and CMS’s and the VA’s Blue Button Initiative are current efforts to share standardized data with the public regarding health and health care in order to foster better public understanding of health care performance and per- sonal health as well as to promote innovative use of the data for the public’s benefit (CMS, 2010a; HHS, 2011a). Finally, many challenges lie ahead for the development of more robust measures in oral health, including the lack of a universally used diagnostic coding system as well as challenges in collecting data from single practice settings. While HHS can require the use of diagnostic codes in their own systems, they cannot mandate their use in the private sector. Overall, the federal government has a great opportunity to assist in this process, both because of the wealth of existing data as well as because of its role in op- erating large systems of care. Measuring Progress Finally, the committee concluded that an effective NOHI needs an on- going process for maintaining accountability, and for measuring progress toward achieving specific goals of improved oral health. Therefore, the committee recommends: RECOMMENDATION 7: To evaluate the NOHI the leader(s) of the NOHI should convene an annual public meeting of the agency heads to report on the progress of the NOHI, including • Progress of each agency in reaching goals; • New innovations and data; • Dissemination of best practices and data into the community; and • Improvement in health outcomes of populations served by HHS programs, especially as they relate to Healthy People 2020 goals and specific objectives. HHS should provide a forum for public response and comment and make the final proceedings of each meeting available to the public. The committee makes this recommendation with the intention that progress made on the NOHI is shared transparently with any and all interested parties. This is an opportunity not only to measure progress in implementing new programs and policies but also to share best practices in the prevention and treatment of oral diseases, to share new knowledge

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221 A NEW ORAL HEALTH INITIATIVE (based on new research and demonstration projects), develop consistent messages about oral health, and to monitor oral health outcomes related to the efforts of HHS. Overall, the committee envisions that this meeting be an opportunity to report on both short-term and intermediate goals (as set by the individual agencies, as discussed in Recommendation 1) and progress on Healthy People 2020 goals and objectives (the overall mission of the NOHI). In addition, HHS needs to develop a mechanism to get public feedback on the programs they are responsible for, ensuring that consumers have a meaningful voice. The committee could not recommend the exact interval of this meeting, recognizing both the time needed for the start-up of new projects as well as the time needed to collect and evaluate new data. The committee also does not intend for this recommendation to preclude additional meetings that HHS might hold internally without a public presence. LOOKING TO THE FUTURE In her presentation to this committee, Dr. Mary Wakefield, Admin- istrator of HRSA, responded to questions from this committee regarding the types of recommendations that might be most valuable for HHS. She recognized that a balance of specificity and generality would be needed but that the recommendations should be “actionable”—that is, recommenda- tions that could be acted upon immediately but might have several methods of implementation and thereby give flexibility. This committee asserts that the framework and details of the previously outlined recommendations does just this. The committee recognizes that many of the recommendations made are not necessarily “new.” However, as the title of this report sug- gests, the challenges and strategies illuminated by Oral Health in America represent and remain the areas that have the strongest evidence for effecting the needed changes. As this committee looks to the future of HHS’ involvement in oral health, questions arise regarding both the long-term viability of maintaining oral health as a priority issue and the likelihood of the recommendations of this report coming to fruition. In this vein, the committee has identified three key areas that are needed for future success: strong leadership, sus- tained interest, and the involvement of multiple stakeholders. The Importance of Leadership The foundation of the OHI 2010 provides many indications that lead- ership for oral health is currently strong. The OHI 2010 is broader than many previous efforts in that it involves many more HHS agencies and pro- grams at multiple levels, which may result in more buy-in departmentally.

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222 ADVANCING ORAL HEALTH IN AMERICA As the NOHI further calls for each agency to develop individual annual plans and short-term goals, it involves individuals at the staff level, who often drive programmatic activity, a structure that veterans of previous ini- tiatives have said can be helpful. However, this also presents the challenge of organizing and directing a multitude of agencies within HHS that are highly independent and autonomous and may not always act in concert. In her presentation to this committee, Dr. Wakefield noted that they were working on signing a memorandum of agreement among CDC, CMS, and HRSA to facilitate cross-agency work (Wakefield, 2010). The new NOHI represents an additional challenge in that this committee calls for the in- creased involvement of and collaboration with leaders from the private sector and other segments of the public sector. These leaders are needed partners to help improve cross-sector communication and coordination in order to achieve significant improvements in oral health. It appears that the current leadership at HHS is capable of meeting these challenges. The OHI 2010 is rooted in strong, high-level interest in that the Assistant Secretary for Health and the Administrator for CMS co-lead the effort. In another example, in her presentation to this commit- tee, Dr. Brand noted that HRSA had recently created an Office of Special Health Affairs within its Office of Strategic Priorities that would focus on two cross-cutting areas: oral health and behavioral health (Brand, 2010). However, while leadership to promote oral health within HHS itself appears strong, some have criticized the erosion of oral health expertise and leadership within HHS. During the public workshop of the committee’s second meeting, a discussion ensued about whether a formal dental leader- ship position should be created in every agency. It was noted that creating a multitude of new positions might not necessarily be matched with enough individuals interested in entering government service, that positions for all types of health care professionals were being eliminated in public agencies to some degree, and that previous successes relied more on the interest from the workers on the ground level. However, the committee does support the need for individuals within HHS from all sectors of health care who are well versed in oral health issues (both dental and nondental professionals) and have an interest in promoting oral health. Sustaining Interest Regardless of how an initiative is structured, much of its long-term viability depends on the interests and efforts of the individuals leading the agencies and HHS, which can change in unpredictable ways over time. For example, a key factor may be whether it can survive a change in presiden- tial administrations, particularly one involving a change in parties. In her presentation to this committee, Dr. Wakefield noted that while there hasn’t

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223 A NEW ORAL HEALTH INITIATIVE been a formal focus on oral health across HHS, they saw the OHI 2010 as an opportunity to leverage assets and interests to improve the recognition of the importance of oral health to individuals and populations (Wakefield, 2010). Tragically, sustained interest is seen and promulgated in the case of Deamonte Driver. Driver’s death in 2007 remains a high-profile example of the worst-case scenario for poor oral health. To date, Driver’s story brings an awareness to these issues that facts or figures cannot achieve. Long-term viability depends on HHS itself making and keeping oral health a priority issue. In spite of evidence for the likelihood of sustained interest, several warning signs have arisen recently that could contribute to a loss of mo- mentum. First, in a February 2011 letter from the Secretary of HHS to state governors regarding state budget concerns, she highlighted areas where states could save money, including modifying benefits. The letter noted that “while some benefits, such as hospital and physician services, are required to be provided by State Medicaid programs, many services, such as prescription drugs, dental services, and speech therapy, are optional” (HHS, 2011b). The committee does recognize that in times of economic challenges, such as we have now, many important health and health care issues are competing for a limited pool of dollars. However, the burden of oral disease, including both the economic and the social impact, needs to be recognized as one of the grand challenges in the health of our nation. Additionally, in early 2011, the CDC released the report CDC Health Dis- parities and Inequalities in the United States—2011 in which oral disease was not addressed at any level. The committee urges CDC to include oral health in subsequent reports. More significantly, in early 2011, the committee learned of the pro- posed downgrading of the CDC’s Division of Oral Health (within the Na- tional Center for Chronic Disease Prevention and Health Promotion) into a branch of the Division of Adult and Community Health (ADA, 2011). Such a change raises two serious concerns. First is that the Division of Adolescent and School Health does not list oral health among the “important topics that affect the health and well-being of children and adolescents” (CDC, 2011) despite the surgeon general’s finding that dental caries was the “the single most common chronic childhood disease” (HHS, 2000). Therefore, placement of oral health into the Division of Adult and Community Health is likely to impede CDC’s ability to give direct attention to the oral health needs of the U.S. population across the life span. The second concern is that such a decision implies that CDC is placing a low priority on oral health. This may be true of other HHS agencies as well. For example, the committee noted that the Administration on Aging does not have any spe- cific initiatives related to the oral health of older adults. The success of the NOHI requires the active involvement of every agency within HHS. Similar

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224 ADVANCING ORAL HEALTH IN AMERICA to the need for consistent messages to patients about the importance of oral health, HHS needs consistent messaging within its own organization that oral health is a priority. Engaging Stakeholders Finally, an important ingredient for the success of the NOHI is public- private partnerships and grassroots involvement. As stated in Chapter 1, an HHS initiative cannot on its own change the entire oral health care system. While the committee agrees that HHS should look for ways to be a leader for the rest of the country, they also need to be mindful of opportunities to partner with and learn from other stakeholders. For example, the com- mittee recognizes the efforts occurring in the private sector that should not be supplanted or ignored. Throughout the recommendations for the NOHI, there are examples and opportunities for HHS to work with other stakeholders to combine efforts, share best practices, and pool resources. Collective efforts in the different sectors are also key to the successful imple- mentation of systems and services at the community level. There is also an explicit effort both in the administrative structure of the NOHI and in the reporting process to engage consumers and their communities so that ef- forts remain patient and community focused, and that HHS remains openly accountable to the people they serve. The committee recognizes that bringing disparate sectors together to effect significant change is a daunting task, but it is one well suited to the mission and responsibilities of HHS. Every effort needs to be made by HHS to collaborate with and learn from the private sector; other public sector entities at the local, state, and national levels; and patients themselves to- ward achieving the goal of improving the oral health care and, ultimately, the oral health of the entire U.S. population. There are many reasons that HHS can and should be a leader in improving oral health and oral health care. However, most important is the burden that oral diseases are placing on the health and well-being of the American people. REFERENCES ADA (American Dental Assocation). 2011. CDC decision to downgrade Division of Oral Health a bad move, ADA protests. http://www.ada.org/advocacy.aspx#top (accessed February 24, 2011). Berwick, D. 2010. Introducing the CMS Center for Medicare & Medicaid Innovation—and innovations.cms.gov. http://www.healthcare.gov/news/blog/InnovationCenter.html (ac - cessed December 29, 2010). Brand, M. 2010. Oral testimony of Dr. Marcia Brand, Deputy Administrator of the Health Resources and Services Administration. Presentation at meeting of the Committee on an Oral Health Initiative, Washington, DC. March 31, 2010.

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225 A NEW ORAL HEALTH INITIATIVE Carey, M. A. 2010. New Medicare/Medicaid projects aimed at cheaper, better care. http:// www.kaiserhealthnews.org/Stories/2010/November/17/cms-innovation-center-berwick. aspx (accessed January 9, 2011). CDC (Centers for Disease Control and Prevention). 2011. Healthy youth: Health topics. http://www.cdc.gov/healthyyouth/healthtopics/index.htm (accessed February 28, 2011). CMS (Centers for Medicare and Medicaid Services). 2010a. Blue Button Initiative. https:// www.cms.gov/NonIdentifiableDataFiles/12_BlueButtonInitiative.asp (accessed January 10, 2011). CMS. 2010b. CMS introduces new Center for Medicare and Medicaid Innovation, initiatives to better coordinate health care. http://innovations.cms.gov/innovations/pressreleases/ pr110910.shtml (accessed December 29, 2010). Crall, J. J. 2009. Oral health policy development since the surgeon general’s report on oral health. Academic Pediatrics 9(6):476-482. HHS (Department of Health and Human Services). 2000. Oral health in America: A report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services. HHS. 2010a. About HHS. http://www.hhs.gov/about/ (accessed December 29, 2010). HHS. 2010b. Advisory committee on training in primary care medicine and dentistry: The redesign of primary care with implications for training. Rockville, MD: U.S. Department of Health and Human Services. HHS. 2010c. Strategic plan and priorities. http://www.hhs.gov/secretary/about/priorities/ priorities.html (accessed December 29, 2010). HHS. 2011a. Community health data initiative. http://www.hhs.gov/open/plan/open governmentplan/initiatives/initiative.html (accessed January 10, 2011). HHS. 2011b. Sebelius outlines state flexibility and federal support available for Medicaid. http://www.hhs.gov/news/press/2011pres/01/20110203c.html (accessed February 24, 2011). IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Mertz, E., and W. E. Mouradian. 2009. Addressing children’s oral health in the new millen- nium: Trends in the dental workforce. Academic Pediatrics 9(6):433-439. Mouradian, W. E., R. L. Slayton, W. R. Maas, D. V. Kleinman, H. C. Slavkin, D. DePaola, C. Evans, and J. Wilentz. (2009) Progress in children’s oral health since the surgeon general’s report on oral health. Academic Pediatrics. 9(6):374-379. Slayton, R. L., and H. C. Slavkin. 2009. Commentary: Scientific investments continue to fuel improvements in oral health (May 2000–2009). Academic Pediatrics 9(6):383-385. Wakefield, M. 2010. Oral testimony of Dr. Mary Wakefield, Administrator of the Health Resources and Services Administration. Presentation at meeting of the Committee on an Oral Health Initiative, Washington, DC. June 28, 2010.

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