March 2018
Volume 14, Issue 3

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The Changing Face of Care

Sociodemographic facets of dentistry impact provision of treatment

Dentistry has always been a healthcare service. However, as we progress into the 21stcentury, the demographics of those who are serving and being served-as well as the methods of delivering those services-are undergoing a shift that may significantly alter the oral healthcare landscape. Inside Dentistry looks at the current sociodemographic facets of dentistry and how the problem of access to care, as well as the proposed solutions, may shape the profession over the coming years.

It is abundantly clear that the current dental care delivery system is unable to properly address oral healthcare needs in the United States. In fact, there are now 5,872 dental health workforce shortage areas across the country. According to Richard Valachovic, DMD, MPH, president and CEO of the American Dental Education Association (ADEA), these shortage areas impact more than 62 million Americans. To close the gap and remove these designations, nearly 11,000 practitioners are needed.

Furthermore, according to a February 2015 report issued by the US Department of Health and Human Services Health Resources and Services Administration (HRSA), entitled, National and State-Level Projections of Dentists and Dental Hygienists in the US, 2012-2025, nationally, increases in supply will not meet the increases in demand for dentists, which will exacerbate the existing shortage. In 2016, the number of dental school graduates was just shy of 6,000, representing a 3% increase from 2015. Currently, dental school enrollment is at nearly its historically highest level, Valachovic says, with more than 24,500 students enrolled during the 2016-2017 academic year. Interestingly, this dental school population is also becoming increasingly diverse from a gender and ethnic/cultural standpoint. For example, women accounted for 49% of the total dental students during the 2016-2017 year, and they comprised 49.1% of the graduates in the class of 2016. In addition, the number of Caucasian dental school enrollees has decreased over time (ie, 55.2% in 2011 compared with 51.4% in 2016) whereas the number of enrollees from other races and ethnicities has increased, Valachovic observes.

This increased diversity could be a beacon of hope for those in underserved areas. As dental school graduating classes become more diverse, access to care for minority groups may improve over time, Valachovic suggests. Data collected from more than 4,500 respondents graduating from US dental schools in 2016 indicate that more than half planned to work in underserved areas at some point in their careers. In particular, the ADEA Survey of Dental School Seniors, 2016 Graduating Class Tables Report indicates that across the surveyed ethnic groups other than Caucasian (ie, American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Native Hawaiian or Other Pacific Islander), more than 50% of the respondents reported that serving one's own racial/ethnic group was either "important" or "very important."

But the issue of access to oral healthcare has more complex variables than patient proximity to dentists and dentist availability in underserved areas. Income, insurance coverage (or lack thereof), and health literacy impact an individual's ability to obtain the dental care that he or she needs. According to Frank Catalanotto, DMD, a professor in the Department of Community Dentistry and Behavioral Sciences at the University of Florida College of Dentistry, there were approximately 180 million individuals who did not access dental care last year, the primary reasons for which were costs and poor oral health literacy. These individuals included children, the elderly, low-income adults, veterans, and countless others from various demographics.

"As part of its Action for Dental Health, the American Dental Association (ADA) is developing and deploying community dental health coordinators across the country to help remove barriers for people in need, raise awareness about how to take care of their teeth and gums, and connect them to needed preventive treatment," emphasizes Joseph P. Crowley, DDS, president of the ADA, who adds that there are more than 130 graduates of the community dental health coordinator program, with an additional 180 in the educational pipeline. "Care coordination is essential, because many community clinics and health centers have the capacity to deliver care if patients know where to access that care."

Although children's oral health remains plagued by oral health literacy issues, the recent reauthorization of funding for the Children's Health Insurance Program (CHIP) is great news for families who are not poor enough to qualify for Medicaid, but who benefit from dental and medical coverage through CHIP, explains Beth Truett, president and CEO of Oral Health America. Many parents aren't aware that a dental visit should occur when a child's first tooth erupts-sometimes before reaching 1 year of age. Scheduling this important preventive visit is key to reducing childhood dental disease and is part of the solution to problems with access to care later in childhood, she says. Additionally, consumer advocacy and awareness efforts that focus on healthy nutrition are needed, such as making fruits and vegetables available and affordable and drawing attention to the lifetime harm caused by sugary drinks, she adds.

"Children are born cavity free, and by raising public awareness, we can help keep them that way," Crowley asserts. "That's why the ADA's Action for Dental Health has prevention and education at its core."

Interestingly, even though vulnerable elderly adults continue to face challenges, more older people than ever before are keeping a greater number of their natural teeth for life as a result of decades of effective prevention and education, Crowley notes. For patients who frequently experience chronic disease management issues, such as those related to hypertension, diabetes, or dialysis schedules, poor oral health can result in additional problems. Compounding these problems is the fact that many may live in states with unpredictable dental benefits due to state budgetary challenges.

"Linking oral health to overall health continues to be one of the opportunities we have when working with physicians and other healthcare providers to promote the value of oral health," emphasizes Crowley. "Good oral health is vital to overall health."

Patrick Lloyd, DDS, a practicing prosthodontist in Minneapolis, Minnesota, suggests that because of the types of patients (ie, those who have had 60 to 80 or more years of dental care) that nursing homes are caring for, those with 100 or more residents should maintain that care by being equipped with an in-house dental facility. Such facilities would enable older patients to conveniently receive regular and routine dentistry without having to be transported in and out of the nursing home. When necessary, these facilities could also provide urgent care.

"Given the number of patients living into their later years who reside in nursing homes and have undergone complicated implant treatments during their lives, the work required to maintain these prostheses is substantial," Lloyd offers as an example. "Broken parts, fractured screws, mobile fixtures, and a whole gamut of complicated situations really require convenient access to technology by the dentists and to care by the patients."

For low-income individuals, access to care involves more than just provider availability. Many studies show that insurance coverage is one of the most important factors-if not the most important factor-in determining if someone seeks regular dental care, says James Bramson, DDS, former chief dental officer at United Concordia Companies, Inc., and former executive director of the ADA. Commercial dental insurance models, which are most often a benefit of employment, are usually sold as group plans. Therefore, for some individuals, the only option left for dental coverage may be an individual dental plan sold on a state exchange. If regular premium payments are not made, the insurance will ultimately be canceled.

Many low-income families need connections to available care that remains underutilized. For example, the DentaQuest Foundation estimates that the average broken appointment rate in health centers is 40%, Crowley says. Community dental health coordinators can help these individuals who may have literacy or transportation issues get the care they need.

"Also, we must strengthen the dental health safety net to provide care to more people in need," Crowley says. "Most states allot less than 2% of their Medicaid budgets to dental services, even though tooth decay is one of the greatest unmet health needs. However, a recent analysis by the ADA Health Policy Institute found that 22 states could add extensive dental benefits under Medicaid for an average cost of 1% of their state Medicaid spending."

For veterans, the eligibility requirements of the US Department of Veterans Affairs can be challenging. Thankfully, processes are beginning to be put in place that will open up referrals to dental offices that can restore their oral health to an optimal level, Crowley says. Many states, such as Illinois, Michigan, and New Jersey, have implemented special programs for veterans with impressive results.

The Role of New Delivery Models

Fortunately, many in the oral healthcare community are taking a cue from the emerging results of person-centered care and financing models in the medical space. They're recognizing that the ultimate goal is to simultaneously achieve a better patient experience, lower costs, and improved population health-all within a financially sustainable model for providers, observes Michael Monopoli, DMD, MPH, MS, executive director of DentaQuest Foundation. He elaborates that person-centered care is built on lifelong relationships among people, providers, communities, and public health advocates who all work toward improving a person's overall well-being.

"Well-being amounts to more than clinical outcomes; nonclinical factors such as environment and demographics play a significant role in the way people interact with the dental care system," Monopoli explains, adding that part of DentaQuest's work is advocating for programs that educate and empower high-risk patients to improve their oral health and access the most appropriate care setting for their needs. "Opening other doors for the underserved requires efforts to develop strong dental homes, support care, and education outside the walls of a dental office and facilitate team-based approaches that are comprehensive, convenient, evidence-based, cost-effective, and efficient."

Among those efforts are models that have changed dental hygienist supervision levels, resulting in a different delivery system. "In some states, dental hygienists have undergone additional education, and select states have effectively created a new provider on the dental team-commonly known as a dental therapist," explains Ann Lynch, director of education and professional advocacy for the American Dental Hygienists' Association (ADHA).

Interestingly, the aforementioned February 2015 HRSA report indicated that increased use of dental hygienists could reduce the projected dentist shortage if they are effectively integrated into the delivery system. In fact, Maine, Minnesota, and Vermont, as well as tribal lands in Washington, Alaska (not state regulated), and Oregon (pilot), have moved forward to address their access to care challenges and now recognize dental therapy as a viable model. Lynch notes that in 2018, many states, including Connecticut, Kansas, Maryland, Massachusetts, Michigan, New Mexico, Ohio, and Washington, are expected to introduce legislation to authorize dental therapy.

According to Natalie Kaweckyj, LDA, CDA, the current president of the American Dental Assistants' Association, utilization of expanded function dental team members also has been correlated with increases in the number of patients who are served. An increased scope of practice for dental assistants benefits not only patients treated in private practices, but also those in public health settings who are most likely to utilize public health clinics and Medicaid benefits.

Lynch admits there is often confusion surrounding the terminology used to describe new oral health workforce models and providers, as states vary in the terms they use. Currently, 40 states allow dental hygienists to initiate patient care in a setting outside of the private dental office without the presence of a dentist. Such policies enable dental hygienists to practice in community settings and reach a variety of patient populations, many of whom would not have access to care otherwise.

For expanded function dental assistants (EFDAs), part of that confusion could stem from significant nationwide variation in the required qualifications, range of allowable services, and job titles for dental assistants and EFDAs, Kaweckyj says. With more than 50 different job titles or designations for dental assistants and EFDAs across the United States, there is a lot of confusion both inside and outside of dentistry, she adds. In one state, a certified dental assistant (CDA) or a registered dental assistant (RDA) might be allowed to perform the same tasks as an EFDA, whereas in another state, a CDA or an RDA could be required to obtain further training to hold an EFDA credential.

"Many states now regulate dental assistants at several levels of practice using a tiered approach for allowable duties and supervision requirements and also restrict expanded function duties to dental assistants who have completed formal advanced didactic and clinical training or who have acquired significant clinical experience," explains Kaweckyj. "Expanded functions that can be performed by appropriately trained individuals might include-depending upon the state-coronal polishing, sealant and/or fluoride application, topical anesthetic application, and nitrous oxide monitoring or administration, as well as expanded restorative, preventive, and orthodontic functions."

Therefore, given the diversity of patients, patient needs, and issues with access to oral healthcare in some areas, Kaweckyj notes that additional benefits to population oral health may occur with the increased use of EFDAs to respond to the changing oral health demands of various patient communities. Likewise, the ADHA believes that dental hygienists also must be integrated into the broader healthcare delivery system to improve the nation's health, Lynch emphasizes.

"A variety of steps are being taken by advocates and states that care about access-to-care issues," confirms Catalanotto. "Dental therapy, which I support as a way to reduce the costs of delivering care to the underserved, is just one of them."

In Minnesota, the first state to enact legislation to create and authorize dental therapy in 2009, such initiatives have proven successful. Today, there are approximately 75 dental therapists in Minnesota, and initial reports indicate that 84% of the patients who received care from a dental therapist were part of a public program. According to Catalonatto, these programs are working, are much less expensive to operate, and do provide basic services that individuals need.

"Many states are looking to authorize dental therapy to complement the dental team and increase access to care. The development and adoption of national accreditation standards for dental therapy education programs has helped to move these deliberations forward," Lynch explains. "ADHA policy defines a mid-level oral health practitioner as a licensed dental hygienist who has graduated from an accredited dental hygiene program and provides primary oral healthcare directly to patients to promote and restore oral health through assessment, diagnosis, treatment, evaluation, and referral services. A dental therapist provides preventative and limited restorative services."

Other practice models that are also helping to improve the access to and delivery of dental care include dental service organizations (DSOs). According to Gary Pickard, director of government and industry affairs for Pacific Dental Services®, due to their economies of scale and the efficiencies that DSO-supported practices gain from utilizing this platform, they are more likely to be larger, able to see more patients, and located in familiar places-from metropolitan to rural areas. Additionally, they're usually open more days per week and more likely to offer early, late, and weekend appointments, Pickard says.

"DSO-supported dentists help make dentistry more convenient and affordable for patients," Pickard observes. "Studies continue to show that traditional fee-for-service dentistry is too expensive for many people. DSOs are more likely to participate in dental insurance plans-even Medicaid-which reduces out-of-pocket costs for their patients."

Insurance, Debt Forgiveness, and New Payment Models

And reducing out-of-pocket costs is a good thing. This is especially true because there is no means or method of patient debt forgiveness, unless services that are not covered at all under a plan are provided to individuals, in which case some means of payment is usually negotiated, Bramson explains.

Bramson further elaborates that insurance payments for dental care are made based on deductibles, co-payments, and coverage policies, with patients being responsible for the difference. Seeking care from a network participating doctor usually means that the dentist has agreed to accept the carrier's schedule of allowances for any procedure and won't balance bill beyond that amount.

Alternatively, non-participating doctors usually balance bill the difference between their fee and the insurance payment. As a result, out-of-pocket costs for the patient are often higher when care is sought from a non-participating doctor, Bramson says.

Not surprisingly, the insurance model for individual coverage in the United States has left most of the individual market underserved, notes Qadeer Ahmed, co-founder, owner, and CEO of ProCare Dental Services, a company that works with employer groups that are legally able to offer self-insurance to reduce prices and expand coverage with a unique plan design. Historically, legacy insurance industry plans really have been geared more toward facilitating group channel distribution, providing pooled coverage, and adjudicating to ensure plan profitability for the carrier and/or viability for the employer.

"However, none of these plans saved patients enough money to expand the access equation because they really didn't address the providers' core cost of operations," Ahmed elaborates, adding that the ProCare model could provide stiff competition to legacy plans for groups, with lower costs, unlimited benefits, and providers receiving full usual and customary reimbursement to ensure quality of care. "This is why such a large percentage of the US population has been shut out from higher-end dentistry unless they are willing to pay cash."

Interestingly, in addition to the standard payment models that the dental industry is accustomed to (ie, third-party payers such as CareCredit®, credit cards), some organizations are experimenting with other ideas, explains Pickard. Among them are self-funded and/or white-labeled options and even in-house discount plans that can be seen as a type of payment model.

Monopoli acknowledges that dental care payment systems need to catch up, which is one reason why new and emerging care delivery models-such as the dental care organization (DCO) model in Oregon (eg, Advantage Dental, Access Dental Plan) and other Medicaid accountable care organizations (ACOs)-are promising. He says that an ACO can more appropriately incentivize team-based care linked to quality, in which team members could include dentists and specialists, advanced practice dental practitioners, mid-level providers, dental hygienists, dental assistants, lab technicians, front office and billing personnel, community dental health coordinators, and clinical care managers.

"There are even groups vertically integrating dental with medical coverage and treatment, realizing a reduction in medical costs from patients with systemic health issues who utilize their dental coverage," Pickard says. "Ultimately, anything that helps patients reduce their out-of-pocket costs or defers payment has a positive impact on access."

Advocacy

Not surprisingly, advocacy issues surrounding access to oral care generally focus on coverage and funding, explains Gary Price, president of the Dental Trade Alliance. In terms of coverage, only a few states provide dental coverage for those who are eligible for Medicaid, and there is no coverage for Medicare beneficiaries, Price says.

"State programs for low-income individuals vary considerably, and oftentimes, states have dental coverage for children but very limited coverage for adults," Bramson adds.

Another advocacy issue is the type of coverage funding/reimbursement that dental plans provide. Dental reimbursement companies are largely focused on total cost, rather than developing systems to encourage a better health outcome for the patient, Price elaborates. Despite significant evidence showing that regular oral care can reduce medical costs, dental coverage is still viewed by policy makers and employers as a cost burden rather than a benefit to improve health.

"This literacy challenge is significant, and perhaps those in the dental community are partially at fault for the literacy issue because we have fallen into the habit of talking about ‘oral health' when educating people about oral disease," laments Price. "Policy makers need to understand that oral care issues can be serious chronic disease issues."

And finally, many agree that one of the most pressing advocacy issues is expanding Medicaid dental coverage, including fully funding it at the state level and reducing any unnecessary red tape that discourages providers from participation in the program, Crowley elaborates. For example, in some states, there are considerable administrative burdens that are actually barriers to participating in the Medicaid program; provider credentialing can happen within weeks in some states and take closer to a year in others.

However, Medicaid programs have been shown to improve access to dental care and promote oral health. The ADA Health Policy Institute has data showing that in states where Medicaid reforms have been implemented, the access for key populations, such as children, has improved significantly. Crowley cites a recent study that revealed that 67% of Medicaid covered children in Maryland had a preventive dental visit in 2016-a statistic higher than some states can claim for privately insured children. Additionally, in states like Texas and Connecticut, the utilization rates of publicly insured children are also very similar to those of privately insured children.

Legislation Impacting Dentistry and Care Delivery

At the time of this article's writing, the US Congress has seemed poised to make significant changes to the Patient Protection and Affordable Care Act, a law that provides several programs encouraging more dental coverage, particularly for children.

"Changes in requirements for people buying health insurance on the exchanges may affect the number of people buying dental coverage, and the continued debate over CHIP also could reduce the total number of children with dental coverage," remarks Gary Price, president and CEO of the Dental Trade Alliance.

"It's so important for children to visit the dentist and start early with good dental hygiene, which is why the ADA supports the 10-year reauthorization of CHIP," Crowley says, adding that "CHIP coverage includes oral healthcare benefits for approximately 9 million children and pregnant women."

On another positive note, there is discussion among some in Congress about expanding dental coverage to Medicare beneficiaries, Price says. Although securing coverage for all Medicare beneficiaries would be a challenge, some advocates are promoting approval for dental care that is ‘medically necessary' for the total treatment of people with multiple chronic diseases, such as diabetes and heart disease, he says.

Other potential gains include a bill called The Action for Dental Health Act (H.R. 2422), which the US House of Representatives is considering, notes Crowley. If passed, this bill would improve oral health in vulnerable populations by enabling organizations to qualify for grants to support activities that improve oral health education and disease prevention. It would also develop and expand outreach programs that facilitate the establishment of dental homes for children and adults, including the elderly, blind, and disabled.

Conclusion

Overall, Monopoli equates access to good oral health with a series of many doors. When opened, they lead to oral health literacy, availability of nutritious food, dentists who accept all different types of health insurance, transportation, and health professionals who speak the same language(s) as their patients.

Furthermore, it's well accepted that charity is not a healthcare system. For this reason, ADA dentists continue to advocate for a better dental Medicaid system and the deployment of community dental health coordinators to help people access public health resources, Crowley adds.

But, Lloyd emphasizes, the standard that the country should be striving toward is access to an equally educated oral healthcare provider for everyone. Dentistry cannot afford to relegate a less-educated provider to some populations due to their location, their economic status, or their ethnicity.

Therefore, when looking at innovative dental care delivery models, making evidence-based decisions is of paramount importance. "When all members of the oral healthcare team are allowed to practice to the fullest extent of their education and scope, collectively, we can best improve the public's oral and overall health," asserts Lynch.

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