The Patient Protection and Affordable Care Act Effects on Dental Care

Transcription

1 The Patient Protection and Affordabe Care Act Effects on Denta Care Keri Discepoo, D.D.S.; Andrew S. Kapan, D.M.D. Abstract Heath care reform has been a subject of debate ong before the presidentia campaign of 2008, through the presidentia signing of the Patient Protection and Affordabe Care Act (PPACA) on March 23, 2010, and is ikey to continue as a topic of discussion we into the future. The effects of this historic reform on the deivery of heathcare and on the economy are subject to specuation. Whie most peope are at east generay aware that access to medica care wi be improved in many ways, few peope, incuding many in the denta profession, are aware that this egisation aso addresses ora heath disparities and access to denta care. It is the purpose of this paper to review how denta care is currenty accessed in the United States and where ora heath care disparities exist, to suggest approaches to aeviating these disparities and to deineate how the changes in denta poicies found in the PPACA hope to address these concerns. The main arguments of organized dentistry, both those in support of and in opposition to the PPACA, are summarized. Heath care reform has been a subject of debate ong before the presidentia campaign of 2008, through the presidentia signing of the Patient Protection and Affordabe Care Act (PPACA) on March 23, 2010, and is ikey to continue as a topic of discussion we into the future. The effects of this historic reform on the deivery of heathcare and on the economy are subject to specuation. Whie most peope are at east generay aware that access to medica care wi be improved in many ways, few peope, incuding many in the denta profession, are aware that this egisation aso addresses ora heath disparities and access to denta care. It is the purpose of this paper to review how denta care is currenty accessed in the United States and where ora heath care disparities exist, to suggest approaches to aeviating these disparities and to deineate how the changes in denta poicies found in the PPACA hope to address these concerns. Background The probem of ora heath disparity and access to denta care were highighted by a number of events, among them, the reease of a pivota report by the surgeon genera entited Ora Heath in America: A Report of the Surgeon Genera 1 in 2000, foowed by a second report in 2003 entited A Ca to Action to Promote Ora Heath. 2 Simutaneousy, there was an erosion of state Medicaid programs, eading to decreased reimbursement for denta care and a subsequent decrease in participating dentists, and itte-to-no adut coverage in many states. 3 There was a we-pubicized 2006 awsuit brought by the American Denta Association and the Aaska Denta Association against the Aaska Native Triba Heath Consortium over the training of mid-eve denta practitioners denta heath aide therapists and high-profie tragedies that incuded the death of a 12-year-od Maryand boy as the resut of an untreated denta infection. 4,5 The debate on PPACA caed attention to these issues as organized denta communities weighed in on how dentistry shoud be invoved in this historic egisation. Denta care in the United States is provided predominanty through private practice. Wending has summarized that as of 2007, 34 NYSDJ august/september 2011

2 Denta care in the United States is provided predominanty through private practice. there were 181,725 active dentists in the U.S.; of these, 166,837 were in private practice. 6 The artice states that roughy two-thirds of the U.S. popuation accesses the private practice deivery system over a given 12-month period. This is a market-based deivery system, owned and run by professionas and reguated at the state eve composed primariy of dentists in private practice who are paid by third party payers or directy from consumers. 7 The remaining one-third of the popuation experiences difficuty in accessing care through the traditiona fee-for-service private practice mode. This is because of the madistribution of dentists, ow or no Medicaid reimbursement and ack of persona denta insurance (up to 43% of the popuation). 8 These patients are more ikey to have higher rates of decayed teeth and more advanced periodonta disease and other pathoogy, compicating the deivery of care. 6,9,10 The segment of the denta profession that provides care to the most needy comprises the denta safety net. The denta safety net incudes hospita, denta schoo and denta hygiene schoo cinics; heath centers; for-profit Medicaid denta practices; hospita emergency rooms; Veterans Administration hospitas; prison denta cinics; Indian Heath Services; and vounteer denta programs. In addition, 20%, or about 30,000 private and group practice dentists in the United States, are Medicaid providers. 11 The separate pieces of the safety net are oosey organized, variabe in program content and poicy, and fai to meet current needs of the popuation. 11 In 2009, in ight of the coming Heath Care Reform Bi, the Institute of Medicine (IOM) hed a workshop entited US Ora Heath Workforce in the Coming Decade to discuss existing trends in dentistry and to offer suggestions on how the needs of the underserved might be met in the future. 12 These ideas were ater pubished as a series of papers in a specia edition of the Journa of Pubic Heath Dentistry. 3,6,8,9,11,13,14 These papers addressed the design of an idea ora heathcare system, with emphasis on improving access to care in rura and urban areas and institutiona settings and making improvements to the denta safety net in genera. The probem with access was underscored by noting that in 2007, there were 4,230 denta heath professiona shortage areas identified in the United States. 8 It was estimated that it woud take 9,642 additiona practitioners to meet the needs at that time and that does not take into account the huge infux of chidren who wi, theoreticay, soon be covered for denta care under the PPACA. One suggested soution is to emphasize the cost-effective technique of preventing denta caries and periodonta disease. Prevention education coud be performed by denta auxiiaries, incuding denta hygienists and expanded duty denta assistants (EDDAs). The ADA proposed creating a community denta heath coordinator (CDHC). The CDHCs woud, preferaby, be peope from the community trained to teach prevention and tobacco cessation and to faciitate access and utiization of denta diagnosis and treatment and who woud return to serve their community in these capacities. 6 Perhaps the most controversia of a the suggested access-tocare improvements is the deveopment of the mid-eve practitioner. This incudes using denta hygienists and denta assistants in new ways and creating new types of providers, incuding: The previousy mentioned CDHC proposed by the ADA. The advanced denta hygiene practitioner (ADHP), an advanced education, master s eve practitioner who can perform restorative procedures, pupotomies, temporary crowns and simpe extractions. 8 The denta therapist or denta heath aid therapist (DHAT), a person with two years post-high schoo experience who performs restorative procedures, pupotomies, temporary crowns and simpe extractions of primary teeth. These therapists work under the genera supervision of a dentist and on coaborative teams. The mode is currenty used in rura areas of Aaska. 8 Nurse practitioner mode, a person who works coaborativey with a dentist in a private denta office and becomes part of a heathcare team, so the patient can have both ora heathcare and primary heathcare deivered. 8 PPACA Specific to Denta Care In response to the access-to-denta-care probems and the suggested soutions to them, the Patient Protection and Affordabe Care Act authorizes, within its 2,500 or so pages, severa major changes in poicy and funding as reates specificay to denta heath. These poicy issues are discussed in detai in other pubications and are briefy summarized in Tabe 1. 15,16 Poicy Arguments From the Obama/McCain presidentia campaign through passage of the PPACA, there were a number of specia interest denta groups working behind the scenes on heathcare reform. Some of these groups incuded the American Denta Association (ADA), American Denta Hygienists Association (ADHA), Academy of Genera Dentistry (AGD), American Academy of Ora and Maxiofacia Surgeons (AAOMS), American Academy of Pediatric Dentistry (AAPD), Chidren s Denta Heath Project (CDHP) and severa other smaer organizations. Some of these groups supported the PPACA, argey based on one or two issues, whie others offered broad support for the egisation. Most of the major denta organizations opposed the egisation, based on severa key issues. NYSDJ august/september

3 Tabe 1 Summary of Major Provisions of PPACA Affecting Denta Care 15,16,20 1. In order for a quaified heath pan to be abe to participate in the Heathcare Exchange, it must incude (among other provisions) pediatric services, incuding ora and vision care. (The egisation notaby eaves out any required coverage for aduts.) 2. Each state is permitted to aow insurance companies to offer the pediatric denta benefit through a stand-aone pan or in conjunction with a quaified heath pan as ong as the pan contains the essentia denta heath benefits required by HHS. 3. The Medicaid and CHIP Payment and Access Commission (MACPAC) is charged with review and the updating of payments to denta professionas. (The egisation notaby eaves this as a gray area.) 4. Medicare Advantage pans generay paid more than comparabe services in the Medicare Fee for Service pans for comparabe services. These additiona payments in some cases paid for denta services. The PPACA requires that the higher payment first be appied towards cost-sharing reductions, second toward weness and preventive care and, asty, toward extra benefits not avaiabe in FFS pans, incuding denta coverage. 5. The bi supports the creation of various Ora Heathcare Prevention Activities, incuding funding for: a. A nationa pubic education program on prevention of ora diseases such as periodonta disease and caries that must be targeted to specific groups: e.g. edery, pregnant women, chidren, disabed and minorities. b. A research-based denta caries management program provided to community-based denta providers, incuding the Indian Heath Service. 6. Schoo-based denta seaant programs. 7. Estabishment of ora heath eadership and program guidance through the Centers for Disease Contro (CDC). 8. Updating and expanding the CDC s Nationa Ora Heath Surveiance Programs to be required in a 50 states, incuding: a. The Pregnancy and Risk Assessment Monitoring System. b. The Nationa Heath and Nutrition Examination Survey. c. The Medica Expenditures Pane Survey. 9. Grants for schoo-based heath centers, incuding referras to and foow up for ora heath services. 10. Medicay accessibe equipment for the disabed, incuding that found in denta offices. 11. Heath workforce provisions, incuding: a. Creating new denta custer heath training programs to incude, genera, pediatric, pubic heath dentists and denta hygienists. This provision aows grants to pay for student and resident training, financia assistance, program deveopment, oan repayment for students and facuty and the provision of technica assistance in pediatric denta training programs. b. Estabishment of demonstration projects for aternative denta heath care providers, incuding CDHCs, Advanced Practice Denta Hygienists, Independent Denta Hygienists, Supervised Denta Hygienists, Primary Care Physicians, Denta Therapists, Denta Heath Aids or other as deemed appropriate by the Secretary of the HHS. 12. New and expanded teaching heath centers to train primary heathcare providers, incuding dentists, in genera and pediatric residencies in ambuatory patient care centers. 13. There are aso a number of other issues that affect sma business and, therefore, private denta practices but are beyond the scope of this paper. In Favor of PPACA Among those denta groups that supported the egisation, the CDHP seemingy was centray invoved in shaping the fina denta provisions of the bi. The group s mission, creating and advancing innovative soutions to achieve ora heath for a chidren, was brought much coser to reaization by passage of the egisation. 17 The egisation wi provide denta coverage to virtuay a chidren (with the exception of iega aiens) and through other provisions, at east in theory, wi dramaticay improve access for that treatment. Workforce grants supporting the deveopment of mid-eve practitioners and Tite VII grants for denta resident and denta hygiene programs wi hep expand access. Grants for schoo-based heath centers wi provide denta care, and the standards set for access for those with disabiities fa squarey within CDHP s mission. Pubic education programs, schoobased denta seaant programs and denta caries management form a ow-cost way to dramaticay improve ora heath. CDHP termed this a systems fix approach, where prevention and management intervention wi occur at community, famiy and individua eves. 17 It is aso notabe that the CDHP is the ony denta organization, to the authors knowedge, that advocates for the pubic and, specificay, for chidren and does not represent the profession. Other denta organizations, representing different facets of the denta profession, were more one-dimensiona. The ADHA supported the egisation mainy because of the funding provided for aternative denta providers and the funding specified under Tite VII for training denta hygienists (in addition to the funding for denta residents, practicing dentists and denta students). 18 The Hispanic Denta Association, whie opposing support for deveoping the mid-eve practitioner, supported the egisation in genera with the focus on access to care for the underserved. The Nationa Denta Association, an organization representing mainy back dentists, supported the egisation, but made an argument against a two-tiered system, whereby the poor and minorities, who often present with the most advanced and compex probems, woud be treated by practitioners with ess training. 16 Opposed to PPACA The most prominent organization of the denta profession is the ADA, representing some 160,000 dentists. The ADA was invoved with obbying efforts, but utimatey opposed the egisation based on three major 36 NYSDJ august/september 2011

4 issues summarized in a etter to Speaker of the House Peosi and signed by the ADA and six other denta organizations that govern most of the denta speciaties (not incuding the speciaties of pubic heath, endodontics and radioogy) and the AAPD. 19 Beow is a summary of their arguments against the bi: 1. Medicaid funding for dentistry is not propery addressed. Without increases in reimbursement to dentists, the egisation wi increase the number of covered chidren, which wi increase demand for services but wi not increase the suppy of dentists who can afford to treat these patients. They aso expressed concern about continued Medicaid administrative barriers and a ack of data-gathering initiatives to hep improve Medicaid coverage. 2. No basic adut denta benefit was addressed, so aduts in underserved communities wi continue to have difficuty accessing denta care. 3. They argued against the funding for deveopment of the mideve practitioner mode caing it, in effect, a two-tiered system, whereby denta care woud be provided to the underserved by non-dentists with ess training. They aso expressed concern about the use of Tite VII funds, formery reserved for denta residents and partiay for training denta hygienists. The AGD, the argest organization supporting genera dentists, pubished a engthy white paper, which argued against mideve practitioners. 20 In addition to some of the arguments previousy stated, the AGD asserted it woud be unikey for these practitioners to create economicay viabe offices or cinics. The academy aso expressed concern for the heath and safety of the patients they treat (an assertion not supported in the iterature); and it argued that access coud better be improved through tax credits to dentists working in underserved areas, schoarships to denta students who agree to practice in an underserved area and recruitment of denta students from underserved areas, who woud have a higher ikeihood of returning to practice in those areas. 15 AAOMS, the argest organization representing ora and maxiofacia surgeons, opposed the egisation on simiar grounds; it was especiay opposed to the mid-eve practitioner having the priviege of tooth extraction. 16 In addition, it shared concerns about a ack of adut coverage, the vagueness of what wi be covered for chidren (especiay the remova of wisdom teeth) and the ack of improvement in reimbursement rates. Athough there is no doubt that PPACA has gone further than any other government program to aeviate ora heath care disparities in this country, it wi ikey fa short of the expectations of its supporters. Passage of this bi provides authorization for its provisions but does not guarantee funding. Funding is a highy poitica issue that NYSDJ august/september

5 wi change with time. Some of the pieces of this egisation do not become operationa unti 2014, most notaby, the state insurance exchanges, aong with the mandated provision of essentia ora heath benefits. The 2010 mid-term eections produced dramatic changes in nationa and state governments, a shift from Democratic to Repubican contro in many cases. With the serious financia issues facing the country, appropriating funds may not be so easy. Cuts in some of the provisions of the PPACA are ikey. Provisions of the bi wi aso be affected dramaticay at the state eve with the eection of many more Repubican governors. 21 Schoo-based centers providing ora heath services, aong with schoo-based seaant programs, may hep with access to care, but chidren in underserved areas often have significant denta disease before schoo age and need emergency denta intervention, 10 so earier access, perhaps at 1 year of age, woud be preferabe. On a positive note, the pubic education campaign for parents and chidren is an inexpensive and powerfu way to improve ora heath of the underserved. The mid-eve practitioner effort wi ikey experience difficuty. Because the egisation specifies at east seven different entities, the $15 miion doars of funding over five years wi be quite sparse for any one program. These different groups wi have to compete with each other to get estabished and wi, at best, be sma movements reegated to imited geographic areas. There is a mandate that each program be accredited by the Commission on Denta Accreditation (CODA), which is a compex and engthy process. Concusion This paper discusses the current status of the provision of denta care and the probems in providing care to the underserved. Approaches to improving access to denta care were reviewed, aong with a summary of the ora care provisions in the PPACA. The organized dentistry arguments both for and against these provisions were summarized and the authors argument that heath care reform wi fa short of expectations of its proponents in the ora heath care arena was presented. The reasons for the shortfa incude ikey poitica difficuties in appropriations at the federa and state eve, given the change in government and the poor economy; faiure to address the ow fees for denta care from Medicaid; difficuties in changing state denta practice acts; and oversight nationay by CODA. Queries about this artice can be sent to Dr. Discepoo at keri.discepoo@ynhh.org. References 1. Ora Heath in America: A Report of the Surgeon Genera. (2000). In: US Department of Heath and Human Services, NIH, Nationa Institute of Denta and Craniofacia Research (Ed.), Pubication # , Rockvie, MD. 2. Nationa Ca to Action to Promote Ora Heath (2003). In: US Department of Heath and Human Services, NIH, Nationa Institute of Denta and Craniofacia Research (ed.), Pubication # , Rockvie, MD. 3. Tomar, SACL. Attributes of an idea ora heath care system. J Pubic Heath Dent 2010;70:S6-S Hoye J. ADA reaches settement in Aaska itigation. ADA News 2007; Juy 16: Otto M. For want of a dentist: Pr. Georges boy dies after bacteria from tooth spread to brain. Washington Post 2007; Feb Accessed Oct. 24, Wending W. Private sector approaches to workforce enhancement. J Pubic Heath Dent 2010;70:S24-S Mertz EA, Finocchio L. Improving ora heathcare deivery systems through workforce innovations: an introduction. J Pubic Heath Dent 2010;70:Supp 1, S Garcia R, Inge R, Niessen L, DePaoa D. Envisioning success: the future of the ora heath care deivery system in the United States. J Pubic Heath Dent 2010;70:S58-S Skiman SDM, Mouradian W, Brunson D. The chaege to deivering ora heath services in rura America. J Pubic Heath Dent 2010;70:S49-S Casamassimo PS. Don t confuse an agenda with a soution: why denta therapists won t do much to improve access. Pediatr Dent 2010;32(2): Edestein B. The denta safety net, its workforce, and poicy reccomendations for its enhancement. J Pubic Heath Dent 2010;70:S32-S The US Ora Heath Workforce in the Coming Decade: Workshop Summary. Paper presented at the Institute of Medicine, Washington, Gassman P, Subar P. Creating and maintaining ora heath for dependent peope in institutiona settings. J Pubic Heath Dent 2010;70:S40-S Hiton IV, Lester AM. Ora heath disparities and the workforce: a framework to guide innovation. J Pubic Heath Dent 2010;70 Supp 1:S Summary of the 2010 federa heath reform aw, the Affordabe Care Act. American Association of Ora and Maxiofacia Surgeons (ed.), AAOMS.com. Accessed Oct. 27, Heath Care Reform Legisation: Impementation Timeines. Chicago, IL: American Denta Association. ADA.com. Accessed Oct. 27, Chidren s Denta Heath Project. Retrieved Oct. 26, 2010, from cdhp/vision_and_mission/vision_and_mission. 18. Statement on Heath Reform. AmericanDenta Hygeine Association (ed.). ADHA.com. Accessed Oct. 17, Letter to Speaker of the House Nancy Peosi. Chicago, IL: American Denta Association. 20. An overview of heath care reform: impact on genera dentistry and sma business. W. S. Consuting (ed.). AGD.com. Washington, DC: Academy of Genera Dentistry. Accessed Oct. 20, Appeby J, Agnes C. With newy eected governors, GOP gains cout to fight heath reform aw. Kaiser Heath News Nov. 3, NYSDJ august/september 2011