Why does policy matter in increasing access to dental care? Shelly Gehshan Director, Pew Children s s Dental Campaign
Agenda Our work Public Health Provide, finance care Facility and professional regulation Health workforce education and training 2
The Pew Center on the States 3
Our Work: Fiscal Health Government Performance Election Initiatives Partnership for America s Economic Success Pew Children s Dental Campaign Pew Home Visiting Campaign Pre K Now Public Safety Performance Project Results First Stateline 4
The Pew Children s s Dental Campaign Our Mission: The Pew Children s Dental Campaign strives for cost effective policies that will mean millions more children get the basic dental care they need to grow, learn and lead healthy lives. 5
Focusing on Three Policy Areas Prevention Community water fluoridation campaigns (CA, AR, MS) National messaging & strategy development Funding for care Advocating for federal appropriations for oral health programs Medicaid reimbursement for fluoride varnish by MDs and RNs Dental Workforce Ensuring adequate workforce to care for children (MN, CA, ME, NH) Research on economics of new models 6
Key State Government Roles in Health Care 7
Public Health
State public oral health activities Design and implement programs for populations, not individuals, e.g. community water fluoridation, sealant programs, surveillance States: Provide financial support State staff plan, coordinate programs, raise funds, identify partners, hire and supervise staff Legislatures set rules for supervision of hygienists in sealant programs 9
Funding for state oral health programs, all sources, 2007 Source: Association of State and Territorial Dental Directors. Summary report: synopses of state dental public health programs data for FY 2006 2007. New Bern, NC: Association of State and Territorial Dental Directors; 2008. p. 14.)
Population on public systems receiving fluoridated water (2008) 75-100% 50-74% 25-49% 1-24% Source: www.cdc.gov/nohss Source: Centers for Disease Control and Prevention, "2008 Water Fluoridation Statistics," http://www.cdc.gov/fluoridation/statistics/2008stats.htm (accessed September 29, 2010).
Sealant programs in high risk schools
The Human Costs of Poor Oral Health Jacobi Hill 6 years old Virginia Diamond Brownridge 5 years old Chicago, IL Dylan Stewart 5 years old Florida 13
Provide, Finance Care
States play a big role Fund local health departments that deliver dental services in some states Shape and fund Medicaid programs, under federal rules, that reimburse dentists, clinics, hospitals, for dental services Decide which of optional populations, services, to cover Set reimbursement rates Set policies that affect FQHC dental programs (outside 4 walls) Decide who can bill Medicaid directly 15
Budget Gap Forecasts Source: National Conference of State Legislatures, State Budget Update, November 2010
Medicaid Fees as a Percentage of ADA Median for 5 Common Children s s Services, 2010 Sources: Pew/MSDA survey of state Medicaid programs, 2010, and ADA 2009 Survey of Dental Fees. 17
Changes in dental payments and use in three states, 2000 to 2004 Source: CMS Medicaid Statistical Information System. Available at: http://www.cms.hhs.gov/medicaiddatasourcesgeninfo/02_msisdata.asp. Accessed October 2007, and Borchgrevink A, Snyder A, Gehshan S. The effects of Medicaid reimbursement rates on access to dental care. Portland (ME): National Academy for State Health Policy, 20008.
Dental managed care in Medicaid Managed care controls many things, including the size of the network Overflow goes to FQHCs 18 states have Medicaid children in managed care Of those, 14 have over 50% of their children in managed care Fees, rules, not always public Source: ADA 2008 Compendium Update, http://www.ada.org/2123.aspx. Accessed March 31, 2010.
Adult Dental Coverage in Medicaid Adult Dental Coverage in Medicaid, 2010 18 14 9 10 Source: ADULT DENTAL BENEFITS IN MEDICAID: FY 2002-2010, ADA
Facility and Professional Regulation
Health professional regulation Legislatures establish, amend, state dental practice acts Governs who can do what, where, for whom, when Sets licensing, certification requirements for providers Defines the practice of dentistry, and auxiliaries Establishes state boards to implement laws 22
Providers and facilities Governors establish, appoint members to, state boards of dentistry, which should: Should ensure both safety of care, and access Balance rights of providers Promote competition and consumer choice Implement the law as enacted Departments of Health regulate facilities on health and safety standards, do inspections, issue fines
Limits of the Current System If you live in the suburbs, if you have a car, plenty of money, dental insurance, and no dental disease, we have the perfect delivery system for you. Charles Bertolami Dean, New York University College of Dentistry 24
7,316 new dental providers are needed to end the dentist shortage 12 30 Ratio of Underserved to Total Population = <10% = between 10% and 20% = >20% Each number represents a dental shortage area Nearly 48 million Americans live in a shortage area 1 110 48 54 11 6 55 118 52 19 117 221 94 7 259 31 86 4 61 526 26 48 185 269 61 22 388 70 28 27 94 244 132 40 56 222 234 55 145 108 27 241 287 208 183 5 523 203 7 (NH) 838 5 (DC) Source: Designated Health Professional Shortage Areas (HPSA) Statistics. Available at: http://ersrs.hrsa.gov/reportserver?/hgdw_reports/bcd_hpsa/bcd_hpsa_scr50_smry&rs:format=html3.2. Accessed January 6, 2011.. 25
Dentists Real Income Over Time Source: Albert Guay, Dental Practice: Prices, Production, and Profit, JADA, Vol. 136 (March 2005), 359. 26
Supervision Rules for RDH Sealant Application 2010 Dentist s exam and direct or indirect supervision required (10) Dentist s exam always required (12) Dentist s exam sometimes required (13) Dentist s exam never required (16) CA OR WA NV ID AZ UT MT WY NM CO ND SD NE KS OK MN IA MO AR WI IL MI IN KY TN OH WV SC NY PA VA NC ME VT NH MA* RI CT NJ DE MD DC MS AL GA TX LA AK FL* HI *FL A change to not require a dentist s exam had been proposed, but not enacted, at the time Pew s report went to press. *MA Recent changes will allow hygienists in schools and other public health settings to place sealants without a dentist s prior exam, but those changes were not yet in effect at the time Pew s report went to press. 27
States allowing hygienists to bill directly for services, 2010 State allows hygienists to bill directly for services Source: http://adha.org/governmental_affairs/downloads/medicaid.pdf
New provider models in dentistry Community Dental Health Coordinator (CDHC) Dental therapist (DT, DHAT) Combined dental therapist hygienist (OHT) Minnesota dental therapist/advanced dental therapist (MN DT and ADT) Advanced dental hygiene practitioner (ADHP)
Discussing New Dental Care Providers WA CA OR NV ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI IN KY TN AL NY PA OH WV VA NC SC GA ME VT NH MA CT RI NJ DE MD DC TX LA AK FL HI Kellogg workforce campaign states Pew workforce campaign states Kellogg and Pew workforce campaign state States with CDHC pilots State with both Pew workforce campaign and CDHC pilot 30
AFHCAN Cart Alaska Federal Health Care Access Network Wireless networking Touchscreen ECG / Video dental camera and otoscope / scanner / digital camera Mobile customized Makes remote supervision possible, safe WWW. AFHCAN.ORG 32
Health Workforce Education and Training
Health Workforce Education and Training Types of Dental Schools in the US (61 total schools in 2010) Source: http://www.adea.org/publications/tde/documents/2010%20dental%20schools%20list.pdf
Loan repayment programs by state Loan repayment programs available National Health Service Corps loan repayment program only Tax credit or National Health Service Corps loan repayment only Limited loan repayment Information unavailable Source: http://www.ada.org/sections/educationandcareers/pdfs/loan_repayment.pdf
In Sum, Policy Decisions Impact FQHCs every day (a few examples) Public health programs reduce need for restorative care Medicaid decisions impact: Coverage for adults, which impacts patient flow, bottom line Ability to get reimbursed at FQHC rate for programs outside 4 walls State funding impacts: Funding for CHCs Workforce decisions impact: Supply of providers, what they can do, where, for whom Education and training impacts supply
Shelly Gehshan 202.552.2075 sgehshan@pewtrusts.org /dental