Underserved Communities Need Innovative Oral Health Strategies Now More Than Ever
| By Frank Catalanotto, DMD; Caswell Evans, DDS, MPH; and Lawrence Hill, DDS, MPH
The National Coalition of Dentists for Health Equity (NCDHE) was formed in 2019 to support strategies to achieve health equity within the United States. Our mission has become even more important as the nation faces significant challenges and health disparities as a result of the COVID-19 pandemic and its many implications for health care access for underserved communities.
The COVID-19 pandemic has clearly brought attention to the health disparities of vulnerable populations, both in terms of pre-existing conditions and outcomes. Our coalition advocates for systems changes in access to care and its delivery, changes in financing structures and effective strategies based on evidence derived from research with a unique focus on oral health equity.
In 2011, the Institute of Medicine (IOM) published recommendations on Improving Access to Oral Health Care for Vulnerable and Underserved Populations (ISBN 978-0-309-20946-5 | DOI 10.17226/13116). Since then, there has been significant progress in addressing the oral health disparities of these populations. We should review the IOM’s work in the current environment and continue to build on it in the months and years to come.
The IOM Committee was charged with assessing the current oral healthcare system to develop a vision to improve oral health care for vulnerable and underserved populations and to develop strategies to achieve that vision. Their recommendations included:
Integrating Oral Health Care into Overall Health Care: The Committee concluded that the separation of oral health care from overall health care is a factor in limiting access to oral health care for many Americans;
Creating Optimal Laws and Regulations: The Committee recommended that state legislatures amend existing state laws to maximize access to oral health care;
Improving Dental Education and Training: The Committee observed that an improved and responsive dental education system is needed to ensure that current and future generations of dental professionals can deliver quality care to diverse populations in various settings;
Reducing Financial and Administrative Barriers: In virtually all recent studies and reports, affordability/costs are the major impediment to accessing dental care;
Promoting Research: The Committee identified a deficiency in the collection, analysis, and use of data related to oral health; and,
Expanding Capacity: The Committee recommended that each state develop and maintain infrastructure and support necessary to perform its core dental public health functions.
More detailed information on each of these six recommendations is included at the conclusion of this blog post.
A number of the recommendations of the IOM Committee are actively being accomplished although significantly more work needs to be done.
Restrictive dental practice acts are being rolled back by state legislators. More states are allowing direct access for dental hygienists; 12 states have now authorized dental therapy legislation. HRSA is funding a number of new initiatives for dental education that focus on the social determinants of health and that increase the dental capacity of FQHCs. Medical Dental Integration and inter-professional education and practice are on the rise.
The COVID-19 pandemic will put significant strain on federal and state budgets to continue adoption and expansion of the IOM recommendations; however, oral health advocates, including the NCDHE, must continue to demonstrate and advocate for the importance of oral health to overall health.
In the same context, it’s also appropriate to incorporate and consider the recommendations of Dr. Marko Vujicic, Executive Director of the American Dental Association Health Policy Institute regarding the inability of the current model of dental care to “drive significant, sustained improvements in oral health going forward care.”
These recommendations included:
Address the Dental Coverage Gap;
Define and Systematically Measure Oral Health;
Tie Reimbursement, Partly, to Outcomes; and,
Reform the Care Delivery Model.
(Journal of the American Dental Association, “Our Dental Care System Is Stuck and Here is What To Do About It”, https://doi.org/10.1016/j.adaj.2018.01.006).
Expanded Information on the IOM Recommendations:
Integrating Oral Health Care into Overall Health Care: The Committee concluded that the separation of oral health care from overall health care is a factor in limiting access to oral health care for many Americans. There are a number of examples which demonstrate that this strategy is being pursued. Some aspects of inter-professional education and practice are being taught and modeled in academic health settings across the country. In all states right now, after only 15 years of implementation, medical professionals are providing oral health preventive services and receiving reimbursement; this has occurred despite early objections of organized dentistry. These medically provided services have been especially important in bringing oral health care to underserved Medicaid populations since so few dentists provide care to Medicaid patients, especially very young children. There are also growing examples of medical dental integration wherein dental hygienists are providing services in pediatric medical offices. This strategy has also been endorsed by Vujicic in his fourth recommendation- Reforming the Care Delivery model. He explicitly called for getting dentistry out of its care delivery silo and engaging the rest of the health system to nudge people into dental care.
Creating Optimal Laws and Regulations: The Committee recommended that state legislatures amend existing state laws to maximize access to oral health care. For example, restrictive dental practice acts have slowed down the development of community-based prevention programs such as school sealant programs delivered by dental hygienists. While science and experience show these to be safe and cost effective, we still have many states where general supervision and direct access for dental hygienists is not possible. The opposition of organized dentistry to dental therapy is another example of restrictive dental practice acts that ignore the data and experience of safety, cost effectiveness and value of dental therapists in providing high quality dental care under general supervision. Again, Vujicic raises this issue in his call for reforming the Care Delivery model, specifically saying “Rise above scope of practice turf wars fueled by fee-for-service payment”. Dental hygiene and dental therapy are in fact scope of practice issues, at least as seen by state legislators.
Improving Dental Education and Training: The Committee observed that an improved and responsive dental education system is needed to ensure that current and future generations of dental professionals can deliver quality care to diverse populations in various settings. Their suggestions are being implemented in some fashion across dental schools in the US. Virtually every dental student today provides some amount of dental care in community-based settings outside of the dental school where they serve vulnerable and underserved patients. Thirteen dental schools participate in the Robert Wood Johnson Summer Health Professions Education Program, providing a 6-week academic enrichment and counseling program to URM college students interested in attending dental school. A majority of dental schools have transitioned to a holistic admission process in efforts to recruit more URM applicants. Title VII HRSA grants for dental education have expanded significantly over the past 15 years, with an increasing inclusion of activities around the social determinants of health and serving vulnerable populations.
Reducing Financial and Administrative Barriers: In virtually all recent studies and reports,affordability/costs are the major impediment to accessing dental care. Click HERE. The Committee concluded that dental coverage for all Medicaid beneficiaries is a critical and necessary goal and that there should be a significant expansion of this coverage for both children and adults. This is certainly consistent with Vujicic’s first recommendation to address the dental coverage gap. We view Block Medicaid Grants and the expanding budget wars in Washington as potential detrimental to this strategy. Alternatively, there has been some progress on providing a dental benefit in Medicare which would significantly improve access for many but then, would also unleash pent up need and demand for dental care. We point out that dental therapists are a proven cost-effective way to lower the costs of delivering dental care, thus extending the number of Medicaid and Medicare patients that could be served with enhanced coverage.
Promoting Research: The committee identified a deficiency in the collection, analysis, and use of data related to oral health. Vujicic indirectly addresses this issue of research with three of his recommendations including the calls to Define and Systematically Measure Oral Health; Tie Reimbursement, Partly, to Outcomes; and moving away from fee-for-service reimbursements. These strategies will not be accepted by the payers/insurers nor the practicing dental community until their success in improving patient outcomes, quality of care and cost effectiveness are adequately documented. Similarly, while all the current data supports the quality, safety and efficacy of dental therapists, more research will be necessary to overcome the objections and PAC dollars of organized dentistry in opposing this new provider. Similarly, the increasing use of Diagnostic Codes which has been resisted previously by organized dentistry will support better outcomes and quality research. For example, the Dental Quality Alliance has been researching and promoting the use of quality measures in electronic health records. More work needs to be done.
Expanding Capacity: The committee recommended that each state develop and maintain infrastructure and support necessary to perform its core dental public health functions. This includes expanding the capacity of Federally Qualified Health Centers and supporting the use of a variety of oral health care professionals- dental hygienists, dental therapists, Community Dental Health Coordinator for example. The Committee also called for the provision of more community-based services, bringing care to the patients rather than asking the patient to go to a dental office.