ORAL HEALTH, UNMET NEEDS, UNDERSERVED POPULATIONS, AND NEW WORKFORCE MODELS: An Urgent Dialogue

Transcription

1 ORAL HEALTH, UNMET NEEDS, UNDERSERVED POPULATIONS, AND NEW WORKFORCE MODELS: An Urgent Dialogue July 16-17, 2012 JW MARRIOTT 3300 Lenox Road, N.E. Atlanta, Georgia

2 EXECUTIVE SUMMARY The passage and now work to implement the Affordable Care Act draws attention to the nation s ailing healthcare system, and its oral healthcare system. Disparities in oral health and the persistent and systemic barriers that prevent individuals from receiving preventative and basic oral health services have been well documented. The Surgeon General s 2000 Report Oral Health of America was the first national call to action to address oral health disparities that disproportionately impacts vulnerable and underserved communities including low-income populations and communities of color. Most recently, the Institute of Medicine and National Research Council s report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations (2011) reaffirmed the need for reform of the existing oral health system and the oral health workforce to assure that everyone has access to quality oral health care across the life cycle. On July 16 th and 17 th, dental providers, researchers, legislative leaders and health professionals gathered at a regional oral health conference (Georgia, Mississippi, and Florida) sponsored by Morehouse School of Medicine to focus on the potential opportunity to improve access to oral healthcare through the use of dental therapists. Conference participants discussed the global evidence for this new type of practitioner and examined the Alaskan dental therapist model. Using Georgia as a case study, conference participants acknowledged the important contribution of community-based efforts to provide oral healthcare for vulnerable population, yet recognized that there is still significant unmet demand and need for care that may be met, in part, by dental therapists. Conference participants agreed that strategies to improve access to care should be: quality driven, locally based, cost-effective, and patient-centered. Ultimately, the vision is to have an oral health delivery system that is comprehensive, coordinated, and that provides continuity of care for all populations. Recommendations for consideration are as follows: Development and implementation of oral healthcare homes. Similar, in concept to patient-centered medical homes, an oral healthcare home would assure quality of care through better coordination to address dental and medical needs of patients, improve access to preventative and curative care, and support patients in managing their own oral health. Adopting or piloting the use of dental therapists As described previously, dental therapists can be deployed in a variety of dental settings to provide oral health education, deliver preventative services, and basic treatment under the supervision of dentists. Allow dental hygienists to practice independently Following Florida s lead, Georgia could allow dental hygienists to do procedures like dental sealants 1

3 without the direct supervision of dentists. In other words, allowing dental hygienists to do what they are trained, education, and proven safe to do. The tremendous energy at this meeting, combined with the passionate commitment to assure the oral health of all children and adults, has the potential to result in catalytic change. Further development and implementation of these recommendations is crucial next step to assuring the oral health of all Americans. 2

4 Introduction Over a decade ago, in a groundbreaking report titled Oral Health of America, U.S. Surgeon General Dr. David Satcher, called out dental and oral diseases as a silent epidemic in the nation. This report documented disparities in access to oral health care, untreated tooth decay, and the risk of being toothless as an adult that disproportionately impacts low-income populations and children and racial/ethnic minorities. Despite increased awareness and attention to oral health, disparities persist and large numbers of children and adults continue to have poor oral health and difficulty accessing dental services. On July 16 th and 17 th, dental providers, researchers, legislative leaders and health professionals gathered at a regional oral health conference (Georgia, Mississippi, and Florida) sponsored by Morehouse School of Medicine. Using Georgia as a case study for the region, the goal was to understand the oral health needs and environment of at-risk and vulnerable populations. To do so, it was important to recognize and acknowledge existing government and community-based oral health programs and services. Moreover, innovative approaches to oral health were presented to help inform recommendations for how to achieve oral health equity in the region. Significant attention was paid to workforce innovations, particularly the dental therapist model. Dental therapists primarily focus on prevention and can provide a limited set of services under the supervision of a dentist. The dental therapist model, while not common in the U.S., has been implemented in 54 countries and there is a growing body of evidence that supports this model as a cost effective strategy for improving access to care. As Dr. John Maupin, Jr., President of Morehouse School of Medicine pointed out, the focus on oral health is timely given the nation s current attention on health reform of its payment systems, insurance systems and ways of providing care. Dr. Louis Sullivan, former U.S. Surgeon General and President Emeritus of Morehouse School of Medicine, noted the persistent disparities in oral health status and oral health care and challenges within the existing oral healthcare system, such as the lack of dentists willing to accept Medicaid. Dr. Sullivan put forward the premise that achieving health equity will require addressing the oral health needs of all Americans, reflecting the fact that the oral health is fundamental to general health. Taking note of the increasing diversity of the nation s population, Dr. Rick Valachovic, Executive Director of the American Dental Education Association and President of ADEAGies Foundation, also put forward that to address disparities a successful pipeline must be in place that encourages and supports the development of dental professionals from all communities, and especially under-represented racial and ethnic (African American, Hispanic, and American Indian) communities. 3

5 Georgia Case Study Oral Health Status Dental disease continues to affect millions of Georgians beginning early in the lifespan. Approximately 52% of third-grade children surveyed in 2011 had a history of dental decay in their primary and/or permanent teeth, of those 19% had untreated decay. (Maternal & Child Health, Georgia Department of Public Health, 2011) It is important to note that while the prevalence of dental decay has remained fairly constant, there has been some notable improvement in getting children care. In 2006, 27% of third-grade children had untreated decay. Yet, disparities persist among children with low income and Hispanic children having poorer oral health outcomes. (Levin, 2007). These disparities by socio-economic status and race/ethnicity are evident in adulthood. One-third of older adults (ages 65-74) with an annual household income of less than $15,000 are likely to lose all their natural teeth compared to less than one-tenth of older adults with household incomes that exceed $50,000. The death rate due to oral cancers among Black males is almost twice as high as the death rate due to oral cancers among White males. (Levin, 2007). Access and Utilization Access to dental care is a major challenge for many Georgians due to the uneven geographical distribution of dental providers and a lack of affordable dental care. Twenty out of Georgia s 159 counties lack dental providers and 48 counties qualify as dental health profession shortage areas (scores of 14 or more) (State Office of Rural Health, March 2012). In many of these underserved areas the nearest dental office is at least 30 minutes away. Rural areas in the state are particularly hard hit and face dental workforce shortages. I know sometimes my colleagues might say that s a maldistribution of dentists, but not a shortage of dentists. However, to a family that is trying to find an office that will take their child themselves and they can t find one, that s still a shortage and not a maldistribution. Dr. Ana Karina Mascarenhas, Associate Dean for Research and Chief of Primary Care, Nova Southeastern University The lack of dental insurance and lack of affordable dental care continues to a major barrier to care particularly for low-income populations. One in four Georgians did not receive care in 2008 because they did not have a dentist or could not find one who would accept Medicaid or PeachCare. As a result of not being able to access dental care, individuals often delay routine care and end up seeking care in emergency rooms. Dr. David Reznick, Chief of Dental Services at Grady Hospital characterized the situation at Gradyas a very real emergency. Grady s overtaxed emergency department is treating 70 to 105 dental emergencies per week. In Georgia, the approximately 60,000 emergency hospital visits for non-traumatic 4

6 dental problems or other oral health issues cost more than $23 million (2007). Dr. Frank Catalanotto, Professor and Chair, department of Community Dentistry and Behavioral Science at the University of Florida College of Dentistry, shared new state data from Florida indicating that in 2010, there were approximately 115,000 emergency hospital visits for preventable dental conditions costing more than $88 million. Vulnerable populations There was broad acknowledgement that children are perhaps the most vulnerable population and that the greatest opportunity to impact oral health over the lifespan is with children. It was clear that assuring care for children is a high priority; moreover, numerous participants stressed the importance of treating all family members, namely parents and caregivers. this issue between adults and children is that it's the vertical transmission of disease is really the barrier. You can't have healthy kids and sick parents or carriers in another situation. Dr. Ron Nagel, Consultant, Alaska Program That said, other vulnerable populations were called out individuals living with HIV/AIDS and the incarcerated population. And interestingly, fifty to sixty percent of those who enroll in the Army have dental problems that must be addressed before they can be deployed. In 2011, approximately 1,861 uninsured or underinsured people living with HIV/AIDS had no dental insurance. Monthly costs for replacing missing teeth in this population are approximately $10,000. Regular dental check-ups for persons living with HIV/AIDS are important because of changes in the mouth that result from a weakened immune system or medications. Dr. Treadwell and colleagues from Morehouse School of Medicine conducted an oral health access survey of 1,501 incarcerated Georgians. The majority of respondents were male (90%) and were of African-American decent (59%). Nearly two-thirds (64%) of the respondents reported not having a regular dentist and not having dental insurance (60%). Two-thirds of the respondents reported having at least one tooth extracted, and among those one-quarter (25%) had four or more teeth extracted. When asked about the reason for having their tooth extracted, 33% of the respondents reported that they did not have money to cover the cost of saving their teeth and another 28% reported that they did not think they had a choice [in treatment options]. African American respondents were more than twice as likely as Whites to reporting having been diagnosed with oral cancer. The implications in terms of numbers of individuals with poor oral health with or without treatment are staggering, given that about 2,000 individuals enter prison every month in Georgia. Dr. Staples-Horne, Medical Director of Georgia s Department of Juvenile Justice (DJJ), in speaking about Georgia s youth stated, unfortunately we [DJJ] have become one 5

7 of the larger, maybe outside of public health, dental providers in the state for young people. DJJ serves over 13,000 children either in secure facilities or in the community. Of these, about half receive dental screenings and treatment if time allows (depending upon the length of stay of the youth.) The dental screenings reveal that although many of the youth may be eligible for Medicaid, few have received dental care. In summary, Georgia has an oral health crisis. There are populations that have a long history of being underserved, whether it is due to the shortage of providers particularly in rural areas or a shortage of providers who will accept Medicaid. [With] the expansion of the Affordable Care Act, there will be upwards of another six million children who will become eligible for dental care through an expanded Medicaid program. At the same time we have only about 20 percent nationally of general practicing dentists participating in their state s Medicaid program, and Medicaid reimbursement rates are pitifully low, which is a barrier. Dr. Caswell Evans, Associate Dean for Prevention and Public Health Sciences, University of Illinois at Chicago, College of Dentistry It is clear that all children and youth are not getting the healthy start they deserve. And the pattern of not getting the routine oral health care is resulting in children and adults seeking care for preventable oral health conditions in emergency rooms that were never designed to provide routine or comprehensive dental care. Government and community programs Georgia s dental community has rallied to tackle the unmet demand for oral health care. There are supportive policies in place that for dental providers who provide charitable care. Georgia s state volunteer healthcare program provides free sovereign immunity coverage, so providers don t have to worry about liability. And some programs (such as the Ben Massell program described below, are able to convert volunteer hours to continuing education credit for providers.) Oral Health Coalition (Oral Health Unit, Maternal & Child Health, Department of Public Health In 2008, the Georgia Oral Health Coalition (GOHC) was re-established to enhance existing oral health prevention programs and strengthen the state infrastructure to conduct oral health surveillance. Working together with the health districts, private providers and community-based organizations, the GOHC has conducted an assessment of the oral health status of Georgia to inform the development of an oral health plan. One major result of the collaborative effort will be a coalition website where individuals can find information on dental services for low-income populations. The Oral Health Unit in the Division of Maternal & Child Health at the Georgia Department of Public Health leads and coordinates the work of the GOHC. 6

8 Georgia Health Sciences Center, School of Dentistry The Dental School s mission is teaching, research, and service. Dr. Connie Drisko, Dean of the School of Dentistry, described how as part of their mission, the School partners with numerous community partners including the Area Health Education Center, Dental Public Health, and the Atlanta University Center Consortium. Over the last decade, there have been significant efforts to provide students with the opportunity to provide community-based services. There are now over 23 community-based clerkship rotations that result in over 15,000 procedures for lowincome and underserved populations conducted outside of the dental school. Beyond community outreach, loan forgiveness grants also supports the provision of free dental care. To date, ten dentists who have received loan forgiveness grants have provided $483,000 in unreimbursed care for 1,500 patients. Office of Dentistry, Veterans Health Administration, Department of Veteran Affairs The Veterans Health Administration provides access to high quality evidence-based dental care to eligible veterans at its medical centers and dental clinics throughout the nation. The Veterans Health Administration recognizes that access to oral health care assists veterans in successfully gaining or regaining employment and that good oral health can contribute to improvements in self-esteem and confidence. In Georgia nearly 500 veterans access dental care either at or administered through the VA facilities in Augusta, Dublin, Atlanta, and through the south Georgia/north Florida VA health care system. To facilitate access, the Veterans Health Administration is placing community-based outpatient dental clinics in areas where large populations of veterans reside. In addition, for those veterans who are not eligible for dental care in VA facilities, the Department of Veterans Affairs is in the process of establishing a pilot program to offer premium-based dental insurance to veterans and certain survivors and dependents of veterans. The availability of an insurance program will enable enrolled veterans and family members to access dental benefits including oral examinations, preventive care, and restorative dental treatment. H.E.L.P. (Healthcare Equality in the Life of Every Person) / H.E.A.L (Health Education Assessment and Leadership) at the Healing Community Center Dr. Charles Moore, as an otolaryngologist founded the HELP (Healthcare Equality in the Life of Every Person) program, a traveling educational resource focused in specific Atlanta zip codes where a majority of head and neck cancers were occurring. The goal of this effort was to empower the lay public with health knowledge and skills to improve the quality and standards of healthcare for the uninsured and the underinsured in Georgia. As a result of the immense need in the communities for comprehensive and integrated healthcare, H.E.L.P. was transformed into H.E.A.L. 7

9 HEAL s (Health Education Assessment and Leadership) mission is to improve the individual s and the community s health and well-being for at-risk and underserved populations by creating a medical home for people they can access, providing them with comprehensive clinical healthcare services. In doing so, the intent is to eliminate disparities in health and healthcare delivery, and at the same time, enhance and build community relationships. This work would not have been possible without the support of numerous collaborators including but not limited to Emory University, Grady Hospital, Piedmont Hospital, Morehouse School of Medicine, Georgia Health Sciences University, Children s Healthcare of Atlanta at Scottish Rite, and Mercer University. Future expansions including converting a mobile oral health-screening unit into a dental and oral health program that will reside in their comprehensive medical/dental facility that provides free and affordable care. With the guidance and assistance of Dr. Rueben Warren and Dr. Connie Drisko from Georgia Health Sciences University, a student rotation through Morehouse is being created that will allow students to gain experience at Healing Community Center. Dr. David Reznik of Grady Hospital is in the process of developing a residency program that will also help to staff the facility. Ben Massell Dental Clinic The Ben Massell Dental Clinic is the only resource in Metro Atlanta offering comprehensive quality dental care at no cost. Ben Massell s clients are at or below 125% of the federal poverty level. The clinic accepts new dental patients per week. Last year just under 4,000 patients received services resulting in about 17,000 procedures worth approximately $2.66 million. What is unique about the Ben Massell Dental Clinic is the staffing model that provides the care. Paid support staff includes five dental assistants and two hygienists. In addition, supporting the clinic are the 155-plus volunteers that provide a minimum of a half a day once a month. Volunteer dentists average 20 years of service to the clinic. The Georgia Dental Association and the North Georgia Dental Society have provided their support for the clinic. Additional support is provided by relationships with the academic institutions and technical colleges through externship programs for dental, dental hygiene, and dental assisting students. Georgia Dental Association (GDA) Mission of Mercy In August 2011, the GDA conducted its first Mission of Mercy event, treating 2,200 patients over two days with care valued at $1.7 million. The next event will occur in June The GDA organizes its members to provide free services, but is also working to advocate for policy and system reforms to make it administratively easy to provide services for individuals with Medicaid and to open up care management networks for qualified dental providers. In addition to the programs highlighted, it was reported that several other clinics throughout Georgia provide pro bono care to the homeless as well as others without 8

10 access to care, insurance or Medicaid. These clinics are partially funded by member dentists, grants, and related means. Workforce Innovation- Dental Therapists The reality is that if we want to improve access to dental care, one of the most strategic ways that we can do that is to provide access to the professions for more people from other backgrounds to come in. Dr. Rick Valachovic, Executive Director, American Dental Education Association What kind of partnerships do we need that we don t have now that can, in fact, better deal with the unmet oral health needs? What kind of changes do we need when we look at providers? Dr. David Satcher, Director, The Satcher Health Leadership Institute, Morehouse School of Medicine, Former U.S. Surgeon General A strategy is needed to ensure that there are sufficient numbers of oral health providers who can deliver care to increasingly diverse populations in various geographical settings. There is an urgent need to adopt and implement new models of care that will increase the availability and type of dental providers who can deliver preventive services and basic treatment; models that can expand the reach of the existing dental workforce. To fill the gap in dental services, what is needed is a dental workforce with the competencies to work in community-based settings and with low-income populations and racially and ethnically diverse populations. Provision of Care by Dental Therapists Dental therapists are limited practitioners who emphasize prevention, can conduct a limited number of procedures, and function as extenders or auxiliaries of dentists. In the U.S., the dental therapists are being used or considered by number of states (KS, NM, VT, WA, OH and MN), and have been in practice since 2003 in Alaska. In 2009, the Minnesota legislature passed a first-in-the-nation licensing bill that authorized dental therapists and advanced dental therapists to improve access to care for underserved populations. Although controversial in the United States, there are 54 countries that have adopted the dental therapist among their oral health providers. A recent review of global literature conducted by Dr. David Nash, Pediatric Dentist and William R. Willard Professor of Dental Education at University of Kentucky School of Dentistry, found evidence that: Support the use of dental therapists in expanding access to care, Dental therapists are effective in providing oral health care with their scope of practice, Dental therapists provide technically competent care, and Employing use of dental therapists can generate cost-savings for dental practices. 9

11 Communities that have or are exploring the use of dental therapists are often those that face a maldistribution of dentists and have under-served populations. More often than not, the under-served populations include low-income populations and communities of color. For communities, such as those in Alaska, that are rural or more remote that have tried and been unsuccessful in recruiting and retaining dentists, the dental therapist model provides an opportunity to assure basic levels of preventative and basic dental services. As described by Dr. Ron Nagel, dental therapists can provide continuity of care, an important factor of quality that cannot be achieved by itinerants and volunteers. Moreover from the patient perspective, the commonality of not being able to access dentists because of geography or income makes the dental therapist model one for consideration. And the truth is, there are people out there who say, well, this is a program in Alaska and the needs are very rural; it s very different. True. But if you re a mother who lives in downtown Atlanta or you re a family member who lives in Seattle or Washington, DC or pick any city in the United States, and you can t get your Medicaid child a dentist, you may as well be living in the smallest village in rural Alaska. Valerie Davidson, Senior Director of Legal & Intergovernmental Affairs, Alaska Native Tribal Health Consortium Questions were raised by meeting participants about the safety of using dental therapists, but as described by Dr. Mary Willard, the DHAT (Dental Health Aide Therapist) Educational Director for the Alaska Native Tribal Health Consortium, dental therapists go through two years of rigorous didactic and clinical training in order to be a certified provider, and then work under the supervision of a dentist. The primary focus of the dental therapists is prevention and the delivery of preventative services, however, given the dire shortage of dentists, basic restorative and curative services can be provided by the dental therapists. Complex dental conditions are referred to dentists. In Alaska, dental therapists are required to be recertified every other year. Because dental therapists most often come from the communities they serve, there is an additional benefit of cultural competence. Cultural competency is especially important in providing oral health education and in efforts to improve oral health literacy. Ms. Aurora Johnson, a dental therapist from Alaska, described her work in communities at health fairs and in schools providing oral health education, oral health screenings, and oral hygiene instructions. Ms. Valerie Davidson, Senior Director of Legal and Intergovernmental Affairs for the Alaska Native Tribal Health Consortium, shared her story of coming from a remote community of 300 members where edentulism (being toothless) was common in adulthood and visits to the dentist were perceived as traumatic (due to painful extractions). Dental therapists who are from the community have been effective in outreach, providing early oral health education and oral hygiene instruction, and overcoming the community s apprehension of dentistry. Their efforts are already beginning to change the oral health lives of the children in the community who now exhibit good oral health behavior. 10

12 Cost-effectiveness of Dental therapists The global literature suggests that cost-savings result from the use of dental therapists. For instance, one study in Australia indicated annual cost savings of 14 to 19 percent in dental expenditures by using dental therapists within their scope of practice rather than dentists. Other studies have indicated that dental therapist school-based services are less expensive than in the private sector. For instance, in New Zealand the average cost of comprehensive school-based dental care was $99 (U.S.) per child compared to $102 (U.S.) for diagnostic and preventative services only per child in the private sector. The opportunity for cost-savings and cost-effective care results from the salary differential between dentists and dental therapists. Therapists are employed on an average of fifty percent the cost of dentists. In 2010, the Pew Charitable Trusts studied the potential impact of dental therapists on private dental practices. Their study found that most private practices by employing dental therapists could start serving Medicaid clients without sacrificing profitability. For solo general practitioners, just as adding a hygienist can result in greater productivity, the same is true by adding a dental therapist, as noted by David Jordan, Project Director of Community Catalyst s Dental Access Project. In the Comprehensive Dental Reform Act of 2012, Senator Bernie Sanders and Representative Elijah Cummings called for pilots of dental therapy and a more integrated delivery system to divert individuals from seeking costly dental care in emergency rooms. The Veterans Health Administration has also been exploring the use of mid-level providers to increase access to cost-effective dental services for veterans. The Office of Dentistry and Veterans Health Administration, together with the Office of Personnel Management developed a career track for expanded function dental assistants (a similar type of provider to dental therapists). This initiative is designed to improve access to dental care in VA facilities while enabling upward mobility for these dental professionals. The reversible procedures performed by these individuals contribute to the safe and efficient delivery of dental care for America's veterans. As the number of expanded function dental assistants increases in VA facilities, it is anticipated that access to care will increase along with increased productivity. Opportunities and Recommendations Dr. Satcher, Director of The Satcher Health Leadership Institute, Morehouse School of Medicine, Former U.S. Surgeon General, emphasized that This is the best opportunity we ve had or maybe will have to really expand access to our health systems in this country. As a result of the Affordable Care Act, millions of Americans will have health coverage either through an expansion of Medicaid or through the Health Insurance Exchanges. Whether dental coverage for adults will 11

13 be included in benefit packages is yet to be determined. However, six million children will become eligible for dental care through the Medicaid expansion. Another critical opportunity resulting from the Affordable Care Act is the initial commitment to implement prevention at the community level. As Dr. Satcher noted, $15 billion set aside in the Affordable Care Act so that communities could work together, could partner with health professionals to really intervene and prevent tooth decay, prevent obesity, prevent things that are really challenging to our future health. However, the support for prevention is fragile with Congress continuing to take money away from the prevention agenda. In discussing strategies and solutions to address oral health disparities, conference participants reiterated that regardless, solutions should be: quality driven, locally based, cost-effective, and patient-centered. Ultimately, the vision is to have an oral health delivery system that is comprehensive, coordinated, and that provides continuity of care for all populations. Oral Healthcare Home One over-arching solution that was put forth was the concept of an oral healthcare home or dental home. While there is not yet one agreed upon definition of an oral healthcare home, the basis of most definitions include the concepts of assuring quality of care through better coordination to address dental and medical needs of the patient, improving access to preventative and curative care, and supporting the patient to be proactive at managing his/her own oral health. While not a new concept, the timing for considering how to fully realize the concept may be now given the provisions of the Affordable Care Act that supports the concept of a patient-centered medical home. Workforce Strategies The current system of oral health care and the existing workforce needs reform if it is to meet the needs of all Georgians. The dental therapist model provides a costeffective solution that allows for the delivery of quality and culturally competent care in community-based settings filling gaps where access to dental care is limited or non-existent. Clearly, with the adoption of new workforce innovations, there should be assurances that individuals receive safe and high quality to care, so as to not perpetuate disparities. Strategies discussed included: Adopting or piloting the use of dental therapists As described previously, dental therapists can be deployed in a variety of dental settings to provide oral health education, deliver preventative services, and basic treatment under the supervision of dentists. 12

14 Allow dental hygienists to practice independently Following Florida s lead, Georgia could allow dental hygienists to do procedures like dental sealants without the direct supervision of dentists. In other words, allowing dental hygienists to do what they are trained, education, and proven safe to do. You have an immediate solution to the preventive part of the access problem in this state [Georgia]. We just passed partial legislation in Florida last year that finally allowed dental hygienists to place sealants with direct supervision I d ask you to consider doing the same thing in Georgia. Dr. Frank Catalanotto, Professor and Chair, department of Community Dentistry and Behavioral Science at the University of Florida College of Dentistry Other Strategies to Improve Access To support the current and future workforce, policymakers will also have to align financial mechanisms to incent the provision of care, especially for Medicaid populations. The issue of Medicaid reimbursement remains a critical issue to be addressed by providers and policymakers. The issue of tax credits should also be considered among incentives that could be used to increase the uptake of Medicaid clients. Summary This conference was held at a momentous period in our nation where there is commitment at all levels to transform the existing healthcare system to one that provides access to care for each and every American. While there is ongoing debate as to how best to do so, there is a shared vision of having a cost-effective system that provides high quality care. For our nation to be healthy, oral health care must be included as an essential service for the health and well-being of all individuals. This report should inform current and future dialogue about how Georgia, Mississippi, and Florida can and must address its oral health disparities and how it will assure equitable access to oral health care for all its residents. What was discussed is outside-the-box, but critical if there is to be true transformation of the oral health care system. This was one of many dialogues among policymakers, dental professionals, community advocates, researchers, and government representatives that needs to take place. Ultimately, the recommendations support the expansion of a workforce through the development of a new type of provider (dental therapists) that is competent, cost-effective, and can fill existing service gaps that disproportionately impact vulnerable and at-risk populations. Moving forward with further development and implementation of these recommendations will be a crucial next step to assuring optimal oral health for all Americans. 13

15 References Levin E, Kanny D., Duval, T., Koskela, L. Status of Oral Health in Georgia: Summary of Oral Health Data Collected in Georgia. Georgia Department of Human Resources, Division of Public Health, November Publication Number: DPH07.155WH. Maternal & Child Health, Georgia Department of Public Health. Oral Health Status of Georgia s Third Grade Children. Findings from the 2011 Georgia 3 rd Grade Oral Health Survey, Georgia State Office of Rural Health. State of Georgia, Dental Health Professionals Shortage Area, Scores of 14 or Greater. Source:// March 29,