Dental Workforce and Access to Dental Care

Dental Workforce and Access to Dental Care Planning for Indiana*
Mark D. Siegal, DDS, MPH, Chief, Mark
D. Siegal, DDS, MPH, Chief,
Bureau of Oral Health Services Ohio Department of Health
Department of Health
January 15, 2009
HRSA’s
HRSA
s Charge
• Develop
p a state oral health strategic
g p
plan that strives
to improve access to oral health care through a needsbased analysis.
– Identify priority needs
• Recommend ways to address the priority oral health/
prevention needs within the State
State.
• Discuss steps needed to implement
recommendations.
– Identify potential resources and funding [local,
state, Federal and private sources]
• Suggest follow-up strategies.
Population
p
of Interest
(Inferred from RFP Language)
• In
I general:l
– “Underserved communities”
– “Populations bearing a disproportionate share
of disease and disability”
• More specifically:
– Populations residing in dental health
professional shortage areas (HPSA)
– Medicaid consumers
– Uninsured (lower-income) population
Activities Cited in Legislation
Activities Cited in Legislation
• Loan forgiveness/repayment
• Recruitment & retention
• Grants or loans for Medicaid providers in HPSAs
p
• Programs (developed in consultation with dental societies) for services in HPSAs
societies) for services in HPSAs
– Dental clinics
– private dental services to enhance capacity
• Place/support dental ,
,
students, residents, and AEGD
• CDE (including distance‐based)
• Teledentistry practice support
• Community‐based prevention ((e.g., fluoridation, S‐BSPs)
g
)
• Promote children going into oral health or science professions
• Faculty recruitment programs (if community outreach mission and record of serving i i
d
d f
i
underserved)
•
Develop, or augment an existing, state dental director office
Products of Grant
• On
O Paper:
P
– A State oral health strategic plan that strives
t improve
to
i
access to
t orall health
h lth care th
through
h
a needs-based analysis.
– Outline of implementation steps for the
strategic plan.
• Real World:
– Implementation
On January 5, 2009, HRSA released an RFP for the next 3‐year
RFP for the next 3
year (2009
(2009‐2012)
2012) Oral Oral
Health Workforce Grant
Will be competitive (expect to fund 25 states)
(expect to fund 25 states)
What Really Counts for HRSA
What Really Counts for HRSA
• Loan forgiveness/repayment
• Recruitment & retention
• Grants or loans for Medicaid providers in HPSAs
p
• Programs (developed in consultation with dental societies) for services in HPSAs
societies) for services in HPSAs
– Dental clinics
– private dental services to enhance capacity
• Place/support dental ,
,
students, residents, and AEGD
• CDE (including distance‐based)
• Teledentistry practice support
• Community‐based prevention ((e.g., fluoridation, S‐BSPs)
g
)
• Promote children going into oral health or science professions
• Faculty recruitment programs (if community outreach mission and record of serving i i
d
d f
i
underserved)
•
Develop, or augment an existing, state dental director office
• Ohio
• Oral Health • Ohio D
Department of t
t f
Health (ODH)
ea t (O )
–Bureau of Oral H lth S i
Health Services
hio
• 7thh most populous state (11.4M)
ral Health
•
•
•
•
•
Uninsured for dental care
Uninsured for dental care
Children’s oral health
Children’s access to dental care
Adult
Adult oral health
oral health
Adult access to dental care
State and County Data Available at
Ohi O
Ohio
Orall H
Health
lth S
Surveillance
ill
S
System
t
• http://publicapps.odh.ohio.gov/oralhealth/
p p
pp
g
1. Dental care is the #1 unmet 1
Dental care is the #1 unmet
g
health care need among Ohio families
2. Four out of ten Ohioans 2
F
t f t Ohi
have no dental coverage
have no dental coverage
Millions
of
Ohioans
3. People do not get dental care mostly due to:
• (lack of) Money (
)
y
• Low expectations
4. Low‐income
4. Low
income families suffer families suffer
most
Access to Dental Care
Dental Disease
Haves
Have
nots
Have
nots
Haves
hio Department of Health
p
Director of Health
Assistant Director for Programs
Assistant Director for Operations
Division of Family and Community Health Services Various Administrative Functions (e.g., budget grants admin
budget, grants admin., HR, purchasing, audit)
(1 of 4 Divisions)
Bureau of Oral Health Services (1 of 6 Bureaus)
An “Evolved”
State Dental
Program
Ohio D
Dental Program:
g m 2009
9
„
„
Staff of 13 FTEs
„ 35 FTEs in late 1980s
2009 budget of approximately $4.6M
66% MCH Block Grant
„ 32% State General Revenue Fund
„ ~3%
3% Other Federal Grants
„ 55% of Budget is Awarded Through
Subgrants
g
„
BOHS from 30,000
,
ft.
Bureau of Oral
Health Services
II. Population
PopulationBased Prevention
II. Access to
Dental Care
III. Oral Health
Information
IV. Oral Health in
Public Policy
BOHS from 5,000 ft.
I. Population-Based Prevention
Bureau off Oral
B
O l
Health Services
•Community water fluoridation
•Grants for school-based dental sealant
programs
•Fluoride
Fl
id mouth
th rinse
i
programs (schools
( h l
in non-fluoridated areas)
II. Access to Dental Care
•Grants for safety net clinics
•Web-based resources for safety
net dental clinics
•Loan repayment & shortage area
designation (HPSA)
•OPTIONS/case management
III. Oral Health Information
•Oral health data collection
•Information, consultation,
technical assistance
•Web-based information
•Ohio Oral health surveillance
system
•Educational materials
•Distance Learning
IV. Oral Health in Public Policy
•Convene stakeholders on oral health
issues
•Collaborate/consult
C ll b
t /
lt with
ith
professional organizations [e.g.,
OCOH, ODA]
•Advocate for oral health issues
BOHS Team Structure
(1 DDS, 1 AA, 1 Secretary, 1 Researcher, 9 RDHs)
• Oral Health Information Team
Oral Health Information Team
– Surveys
– Surveillance system
S
ill
t
– Web‐based information
•
•
•
•
School‐Based Oral Health Team
Community Water Fluoridation Team
Access to Dental Care Team
Maternal and Child Oral Health Promotion
Maternal and Child Oral Health Promotion Team
otpourri
erspectives on Access to Dental Care
Bureaucrats’ View of Access to Dental Care
VULNERABLE People
(Low(Low
- Income, Uninsured)
PRIVATE
Private dentists who
p Medicaid ((~1900))
accept
(~5000 Primary Care)
( 925)
(~925)
SAFETY
NET
CLINICS
OPTIONS
DDS
(105)
No Care
Patients’-Eye-View of
A
Accessing
i D
Dental
t lC
Care
Promoting
factors (e.g.,
school
requirements)
Patient’s
(P
(Parent’s)
’ )
Perceptions
Intimidation factors:
1) Ability to pay/
insurance
2) Family history
Dentist
availability
Uninsured
Seek
care
Don’t
seek
care
Medicaid
Private
Insurance
G t
Get
dental
care
1st
Vi it
Visit
3) Transportation
4) Child care
5) Time off from job
6) Language barriers
D ’t receive
Don’t
i care
Uninsured
– 1.2 million (10.7%) 1 2 illi (10 7%)
Ohioans have no health
health
insurance – 4.25 million (38%) lack dental coverage
• 670,000 Children (23%) • 3.6 Million Adults (43%)
– Seniors (66%)
Delivery System
• 6035 licensed dentists residing in Ohio
– 80% are primary care dentists
– Distribution issues
• 57 Dental HPSAs (by definition, dental HPSAs
don’t have enough dentists)
• 122 Safety Net Dental Clinics
– Range of capacities
– Includes 2 dental schools, 9 GPR/AEGDs and
5 Pediatric Dentistryy Residencies
Ohio’s Dental Safety Net
(122 clinics)
Preventive
10%
Oral Surgery
4%
Comprehensive 86%
Ohio’s
Dental Safety Net
Ohio s Dental Safety Net
Limited hours
15%
Part‐time
15%
Full‐time
64%
Ohio’s Dental Safety Net
(105 Comprehensive Clinics)
School District
2%
Dental School
7%
Dental Hygiene School
10%
Other (Non‐
profit, faith based)
22%
Local Health Dept
17%
FQHC Look‐a‐
like
2%
FQHC
31%
Hospital
19%
Medicaid
• Largely managed care (MCP) since 2006
– Dental benefit administered as F-F-S by MCPs
• Coverage of children mandated through EPSDT
• Adult dental benefits are fairly comprehensive
• Fee increase in 2000ÆReduction in
2006ÆRestored in 2008
• ~1/3
1/3 of Ohio dentists had a Medicaid claim in
2007
• ~1/3 of Medicaid consumers had a dental visit in
2007
Do Ohio dentists see young children and those with Medicaid?*
100%
100% 100%
91%
90%
80%
0-2 y.o.
69%
70%
60%
3-5 y.o.
50%
34%
40%
30%
22%
20%
Medicaid
(0-5 y.o.)
10%
0%
Pediatric Dentists
(2-3% of Dentists)
General Dentists
(>80% of dentists)
*reported by dentists
Ohio Dentists and Medicaid (for children through 5 years of age*
hild
th
h5
f
*
80%
70%
69%
60%
Accept
p
Medicaid
for 0-5 y.o.
patients
50%
40%
29%
30%
22%
20%
7%
10%
Accept
Medicaid
with no
limitations
(0-5 y
y.o.)
o)
0%
Pediatric Dentists
General Dentists
*reported by dentists, 2002
The Dentist Factor
Dentist geographic availability
Effective Dentist
availability
1) Under age 3 yrs.
2)) D
Disability
sab l ty
3) Medicaid
4) New patients
Medicaid
revention
ti
• Fluoridation Statute
Fluoridation Statute*
– (91% of population on PWS’s have F‐water)
• School‐based sealant programs (S‐BSPs)*
School based sealant programs (S BSPs)*
– 20 Programs
• State funds 16 local programs that serve 40 counties
S
f d 16 l l
h
40
i
• 30,000 children/year receive sealants
• Fluoride Mouth Rinse in non‐F areas
Fl id M th Ri
i
F
• Fluoride varnish by primary care providers (Medicaid)
*Recommended by Guide to Community Preventive Services (Evidence-Based)
hio ral Health(& Related) lans
1))
2)
3)
4)
5)
6)
7)
SState dental program (BOHS) work plan
a e de a p og a ( O S) o p a
–
http://www.odh.ohio.gov/odhPrograms/ohs/oral/or
alfaq/mission.aspx
MCH Block Grant Plan
State Health Department Strategic Priorities
Director of Health’s Task Force on Access to Dental Care Recommendations (2000, 2004, 2009)
Dental Workforce Roundtable
Ohio Dental Assoc. Strategic Plan
O lH l hC
Oral Health Capacity Building
i B ildi
–
ODH partnership with three charitable foundations
Previous Ohio lanning Processes:
Wh
When,
Wh
Why, Wh
Whatt H
Happened?
d?
Director of Health’s l h’
Task Force on Access to Dental Care Care
2000
Participants in the Process (Over 70 People)
•
•
•
•
•
•
•
•
Business
Consumers
Dental Education
D t lP
Dental
Professionals
f
i
l
Hospitals
Labor
Legislators
Local Government
• Non-Government
Public Health
Programs
• Not
Not-for-Profit
for Profit Social
Service Agencies
• Pediatrics
• Schools
• State Agencies
Adaptation of the Institute of Medicine’s Ad
t ti
f th I tit t f M di i ’
definition of access to primary care:
" The ability of all Ohioans to acquire timely
oral health care services* necessary to
assure orall function
f
ti and
d ffreedom
d
ffrom
pain/infection."
* For practical purposes, oral health care services
g roughly
g y equivalent
q
to those
were defined as being
listed in the Medicaid provider handbook.
Four Groups of Recommendations
Four Groups of Recommendations
1. Improve and expand Medicaid/SCHIP
2. Increase capacity
p
y of the dental care deliveryy
system to serve vulnerable populations.
pp communityy p
partnerships
p & actions to
3. Support
improve dental care access and communitylevel oral health infrastructure.
4. Increase decision-makers’ and the public’s
awareness of oral health and dental care
access issues.
i
The recommendations of the Ohio Direcotr of Health’s Task Force on Access to Dental Care (2000 & 2004) can be found (
)
at:
http://www odh ohio gov/odhPrograms/ohs/oral/oralfaq/T
http://www.odh.ohio.gov/odhPrograms/ohs/oral/oralfaq/T
askforce.aspx
Most of the 2000 recommendations were not accomplished
Some things did happen…
Some things did
Dental Care Case
Management
Programs
OSU’s “Ohio Project”
State
St t Budget
B d t
Medicaid:
Fluoride
Varnish by
Primary Care
Providers
Expansion of dental care safety net
State Dentist
Loan
Repayment
Program
http://www.odh.state.oh.us/ODHPrograms/ORAL/ http
//www odh state oh us/ODHPrograms/ORAL/
Rpt2000/DTFRpt04.pdf
Director of Health’s
Task Force on
Access to Dental
Care
2004
2004 DTF
2004 DTF
• One day process with smaller group – (19 rather than 40)
• Revisited 2000 Recommendations
– Recycled some
– Dropped some
– Added a few
Add d f
• Realistic Prioritization Approach per Budget Realities
– Sh
Short‐term Strategies
tt
St t i
• e.g., “Maintain the dental Medicaid program”
– Long
Long‐term
term Strategies
Strategies
• e.g., Michigan’s Health Kids Dental
Director s Task Force on Director’s
Task Force on
Access to Care: 2004
2004
Because of extensive, but inconclusive, discussion on workforce‐specific approaches, one of the recommendations of the 2004 Task Force was:
• Establish a dental workforce task force that will report its recommendations to the Director of Health..
Health
Ohio Dental Workforce Roundtable (DWFRT) was the result of the DTF 2004 Recommendation
• Conducted by Health Policy Institute of Ohio
• Experienced professional facilitator
Experienced professional facilitator
• "Workforce issues are only one aspect of what limits the access of vulnerable persons to oral
limits the access of vulnerable persons to oral health care. Further, this group does not see them as the most significant obstacles.”
g
– “For some there is a concern that, in an era of limited resources, investing in workforce innovations may undermine efforts to address other issues.”
d
i
ff t t dd
th i
”
Dental Workforce Roundtable Process
• Heard presentations from ODH and guest speakers from California (UCSF), Chicago (ADA) and Michigan (UM) Case Dental School
and Michigan (UM), Case Dental School
• Heard presentations from roundtable members
• Developed core values linked to workforce
Developed core values linked to workforce
• Reviewed literature on workforce approaches
Discussed and scored various approaches
• Discussed and scored various approaches, resulting in a report that included recommendations that were submitted to the Di
Director of Health
fH l h
Core Values (sample)
Core Values (sample)
• All people living in Ohio, especially children, should have access to reasonable and reasonable and adequate
d
h lh
health care, including oral health l d
lh l h
services.
– Society cannot afford to provide an optimal S i
ff d
id
i l
level of care to all of the most vulnerable, but
– Society cannot afford to deny any person Society cannot afford to deny any person
access to reasonable and adequate care.
Core Values (sample)
Core Values (sample)
•
Reasonable and adequate oral health Reasonable
and adequate oral health
services include:
• B
Basic diagnostic services,
i di
ti
i
• Services that result in being free of pain and infection
and infection,
• Basic restorative services that preserve or restore function
restore function,
• Basic esthetics, and
• Prevention & education.
Prevention & education
Statement of Conditions (sample)
•
•
There are alternative workforce strategies that have been tried successfully in other y
parts of the United States.
There is not an unambiguous, consistent
There is not an unambiguous, consistent body of qualitative or quantitative data that p
provides clear insight into the effectiveness g
of workforce options.
Workforce Approaches Workforce
Approaches
Considered
• A. Increase the supply/use of allied oral health A I
h
l /
f lli d
lh l h
care personnel in underserved areas. • B. Increase allowable duties/functions c ease a o ab e dut es/ u ct o s
• C. Reduce supervision requirements • D. True mid
D. True mid‐‐level professionals • E. Foreign
E. Foreign‐‐trained dentists (in SN/PH settings) • F. Dentists
F. Dentists‐‐in
in‐‐training (dental students, GPR) • G. Encourage volunteerism (generally in PH G E
l t i (
ll i PH
settings) • H. Financial incentives (loan repayment, tax (
p y
,
credits)
2009 DTF Process
• 17-20 members
• December
D
b 4
4, 2008 DTF organizational
i ti
l mtg.
t
• January-March 2009 five regional
stakeholders
t k h ld
fforums
• DTF meets to develop strategic and
implementation plans (dates TBD)
– April 2009
– May 2009
– June 2009
– July 2009 (Final plan to HRSA in August)
None of the DWFRT Recommendations were
Recommendations were Accomplished and no organized, inter‐disciplinary group efforts sought to address those
sought to address those recommendations
essons Learned
L
d
The Journey
The Journey
What I Learned i
in School
What I Wh
tI
Learned in
Learned in Life
What I learned in school
What I learned in school
$$$
$$$
$$$
What HRSA Learned in School
• Develop
p a state oral health strategic
g p
plan that strives
to improve access to oral health care through a needsbased analysis.
– Identify priority needs
• Recommend ways to address the priority oral health/
prevention needs within the State
State.
• Discuss steps needed to implement
recommendations.
– Identify potential resources and funding [local,
state, Federal and private sources]
• Suggest follow-up strategies.
What I’ve
What I
ve learned in life
learned in life
For every complex problem, there is a solution that is:
•
•
•
•
Quick
Easy
Cheap, and
Wrong
Inconvenient Truth: Access to Dental Care for
V l
Vulnerable
bl P
Populations
l ti
iis a C
Complex
l P
Problem
bl
• Access to dental care problem in
involves:
ol es
– A lack of dental insurance coverage/ability to pay for
dental care
– A lack of (dentist) enthusiasm for treating Medicaid
consumers
– Lower expectations--and demand for services--among
vulnerable populations
– A host of other issues
• Burden of uncompensated care on safety net
• Transportation, getting off work, child care
– Etc.
Complexity 101: Medicaid
• Six Steps for improving access through Medicaid and SCHIP:
Medicaid and SCHIP:
1.Developing a supportive policy environment
2.Finding and sustaining funding for improved access and benefits
3.Supporting enrollees’ use of dental services
4.Ensuring an adequate provider base
5.Making provider participation easier
6.Investing in prevention
6.Investing in prevention
NASHP/Kaiser Commission on Medicaid and the Uninsured
Economy
Economy
State
St t Budget
B d t
There Often are Unrealistic Expectations for the Potential Results of Public Funding h
i l
l f bli
di
Dental Expenditures
Dental Expenditures
• Nationally, public spending for dental care is a small fraction of total dental care costs (mostly Medicaid). – <6%, in 2002
<6% in 2002
• In 2007, ODH oral health budget ($4.6M) was ~2.5% of Ohio Medicaid expenditures for dental care. • Do the math Approximate Perspective
Approximate Perspective
$4.6M
Budget
3-legged Stool of Success
C
C
C elestial
alignment
Group Dynamics
Coalesce
Coordinate
Collaborate
Communicate
lash
ce
Coordinate
Collaborate
Communicate
Bad Oral Health Plan
Karma Dental D
l
Medicaid
School
State Title V Program
State
St
t Oral
O l
Health Plan
State Dental l
Association
State Primary C
Care Assoc.
A
((“For
For the
people…”)
State
Oral
Health
Program
State Dental Hygienists’
Hygienists’ Association
OTHERS
(e.g., advocates, e g advocates
foundations)
Good Oral Health Plan Karma
ce
Coordinate
Collaborate
Communicate
Medicaid
State Title V Program
Dental School
State Primary State
Primary
Care Assoc.
State* Oral
Health Plan
State Dental Association
(“For the
people…”)
State
Oral
Health
Program
State Dental OTHERS
Hygienists’ Association (e.g., advocates, f
foundations
d ti )
“Too Good to be True”
Oral Health Plan Karma
State Title V P
Program
State Dental State
Dental
Association
Dental Medicaid
School
State Oral
Health Plan
(“For the
people…”)
OTHERS
State Primary State
Primary
Care Assoc.
State
Oral
Health
Program
State Dental H i i ’ (e.g., advocates, Hygienists’ Association foundations)
coalesc
e
Coordinate
Collaborate
Communicate
Plan for the Future!
C
C
C elestial
alignment
li
mark siegal@odh ohio gov
mark.siegal@odh.ohio.gov
www.odh.ohio.gov/odhPrograms/ohs/oral/oral1.aspx