White paper full document2 - Colorado Dental Association
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A Review of Oral Health Status,
Access to and Utilization of
Oral Health Care Services in Colorado
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June 2011
A Review of Oral Health Status, Access to and Utilization of Oral Health Care Services in Colorado
POSITION STATEMENT AND RECOMMENDATIONS
Experts now recognize that the health of the mouth is critical to the health of an individual. Numerous studies confirm that many systemic adverse health conditions have manifestations in the mouth. Adverse oral health conditions affect three aspects of daily living: 1) Systemic health – periodontal disease has been proven to have a direct impact on heart disease, diabetes and low birth weight babies; 2) quality of life – edentulism (without teeth), soft tissue lesions, oral clefts and missing teeth affect the ability to eat and function; and 3) economic productivity – dental disease accounts for many lost work and schools days. Good oral health is essential to overall health, and access to dental care is important for the health and well being of Coloradans.
Numerous factors impact access to dental care: oral health literacy, health status, financing care, utilization, safety net, workforce, external influences, government programs, and innovative outreach. Barriers may impact an individual’s ability to access oral health care services and solutions to overcoming those barriers must be multifaceted. Any solution that compromises the welfare and safety of the patient should not be considered, even in the spirit of “any care is better than no care.” There is no health or financial gain in compromising oral health care. Our goal must be to open the doors of access to care while ensuring the health and safety of the public.
Accessing dental care is uniquely individual. According to the Academy of General Dentistry, solving the access problem requires that those who are interested in helping a person access care “recognize and address the unique barriers encountered by an individual seeking dental care, including the patient’s perceived need for care, oral health literacy, dentist and dental team distribution, financial circumstances, special needs, transportation, location, language, cultural preferences and other factors influencing entry into the dental care system.”[1] Access to oral healthcare is far more complicated than a one solution response.
The dental profession recognizes the importance of oral health and the ability of Coloradans to access dental care. The profession has been an outspoken advocate for improving access to care for all population groups. The Colorado Dental Association has a long-standing goal of educating dentists and patients about the importance of establishing a dental home, and our many volunteer supported dental charities do the best we can to provide care to those in need. We have also taken the lead in advocating for government assistance programs for those who cannot afford care.
An adequate workforce is a key element in providing access to dental care. The determination of an adequate workforce is more than the number of dentists or dental auxiliaries within a state. From a workforce perspective adequate access is affected by the following: the geographic distribution of dentists and dental auxiliaries, the availability of specialty practitioners, and the number of dentists that participate in government-funded programs. A numerical shortage of dentists may exist in a few states. However, Colorado's current dentist workforce number is adequate and a plan is in place to expand to meet the future workforce needs in Colorado through the expansion of the University of Colorado's School of Dental Medicine. In 2000 (most recent statistic available), Colorado ranked sixth highest in the country for dentists per capita, with a dentist-to-population ratio of 70 per every 100,000 Coloradans (or 1:1,429).[2] The federal Health Resources and Services Administration (HRSA) estimates that a 1:3,000 dentist-to-population ratio is required to meet the current demand for dental care.[3] The Colorado Department of Labor projects expansions for the dentist workforce in Colorado at least through 2019.[4] In addition, the University of Colorado’s School of Dental Medicine recently announced that it will increase dental school admissions by 50% starting in 2011. This will yield a substantial increase in the dentist workforce starting in Colorado by 2015. Colorado also has an excellent and competent supply of dental assistants and dental hygienists who complete the dental team’s ability to provide quality dental care to the citizens of Colorado. Colorado is already one of the more progressive states on dental workforce, a fact that many overlook. Colorado has allowed the independent or unsupervised practice of dental hygiene for over 20 years and is broad on the duties dental assistants can perform under a dentist’s supervision. The Colorado Department of Labor projects substantial growth for the dental hygienist and dental assistant workforce in Colorado at least through 2019. [5]
Recently, groups outside the dental profession entered into the discussion of improving access to oral health care. Most of these groups are single focused in their solution to the multifaceted problem of accessing oral health care. Some entities propose a new category of dental provider called a Mid-Level Provider (MLP) as the solution to access. This approach may be the result of frustrations from losing government funding battles for Medicaid and SCHIP programs and believing that some care is better than no care. While these groups may be well intentioned, their solution is not based on science or data that support adding MLPs to the dental workforce actually improves access or lowers the cost of care.
Two states’ (Alaska and Minnesota) have implemented a dental MLP as a solution to access to oral health care. Decision makers in these states looked to unproven solutions without considering quality of care, the potential ill-effect of the patient’s health or the potential additional cost. In good conscience they believe this to be a quick and an adequate response to the access to care issue. However, creating a new category of provider will not solve the complex issue of access; it will only create a two-tiered delivery system.
New Zealand has employed MLPs since 1921. However, reports indicate that this strategy has not solved access to dental care or improved the oral health of its citizens. If this strategy had been successful, New Zealand would not be experiencing pockets of oral health disease at the level of regions traditionally characterized by poor oral health status. Indeed, in some areas the severity is at the level of developing or Eastern European countries.[6] The recent data prompted New Zealand to reconstruct its dental delivery system. What this information underscores is that merely creating different types of providers to augment care from a dentist does not provide appropriate and accessible oral health care. In pursuing improved oral health access, Colorado should not compromise quality and expose patients to a lesser standard of care that has not worked in other countries.
There are distinct differences between the delivery of dental and medical treatment. Following the medical model is not the solution to access to dental care. Like most other states, Colorado is experiencing a significant shortage of primary care physicians. Yet, the medical community struggles with access to primary medical care despite having created a plethora of non-physician primary care clinicians (NPCCs), such as physician assistants (PAs), nurse practitioners (NPs) and certified nurse midwives (CNMs). In spite of these efforts, access to health care for many Coloradans is limited or unavailable, especially in rural areas, and the cost of delivering health care continues to increase annually. Like most states Colorado is experiencing a shortage of primary care physicians, which may be exacerbated by the creation of MLPs.
Decision makers and health care advocates who are interested in seeking a sustainable solution will recognize that lowering the standard of care will not solve the problem of improving oral health, will not increase access and will not lower costs. The dental profession, decision makers and other interested parties must work together to examine what is broken, what works, and what we can do to meet the challenge to provide Coloradans with quality dental care while increasing access to care for all. Many solutions are required, and the solution for one state is not likely to be the same for all states. We must be understanding of those who employ extraordinary measures in an attempt to solve their health care delivery issues; however, we must never let their compromise set our standard of care. Other states’ solutions should not be adopted as the professional standard of care or accepted as Colorado's solution to access.
Colorado's dental professionals will stand firm on core principles. The performance of education-appropriate procedures must be a minimum requirement. Education is the foundation of science. Dentists are doctors with an undergraduate degree and a minimum of four additional years of dental school. Many continue for advanced studies in a General Practice Residency or in one of nine specialty programs. Contrast these requirements with a dental assistant who is not required to receive any formal training in Colorado and works under the direct supervision of a dentist, or a dental hygienist who in Colorado has at minimum a two-year associates degree before treating patients. Dental hygienists are highly trained and educated but a two- or four-year undergraduate program does not prepare them to fully diagnose or perform irreversible procedures. Some proposals, like a two-year training program for a Dental Health Aid Therapist (a type of MLP), would allow under-educated individuals to diagnose disease and perform irreversible procedures. Taking a step back in education is not a solution; it is a problem that will adversely impact the oral health of future generations.
Areas of the current dental delivery system could be improved, but lowering the education standards by creating a dental MLP is not one of them. The dental delivery system could work more effectively if not faced with the limitations of severely underfunded government programs or programs that neglect entire patient populations – there is no acceptable dental benefit for adult Medicaid patients in Colorado. These constraints contribute to ongoing challenges with recruiting and retaining dentists as Medicaid providers and hamper dental care from being delivered to the population that needs government assistance. Employer plans have some of the same problems. The dental benefit for most employees is capped at $1,000 or $1,500 annually and has not changed since the late 1960s. This is not consistent with medical benefits and can be a barrier for employees who seek care. We must also work to address delivery system concerns around the composition and distribution of dental providers. Currently, there are 9 counties in Colorado without a dentist[7] and around a dozen without a dental hygienist.[8] Further, many Coloradans with dental coverage do not go to a dentist because they do not understand the importance of oral health. We must put education programs in place to increase the oral health literacy of Coloradans.
In our quest to improve Colorado's access to oral health care we must never compromise patient health or safety. We must look for ways to bridge the gaps between the “haves” and the “have-nots” by collaborating with those who truly want to work toward solutions that allow all Coloradans to have the same quality oral health care that each of us wants for our families.
The Colorado Dental Association’s (add other groups at conclusion of process + throughout) proposed solutions to improving the health status of Coloradans by improving the access to and the utilization of oral healthcare include, but are not limited to, the following:
RECOMMENDATIONS
• Health Status:
1. Increase the proportion of eligible low-income elementary school children who receive sealants on the chewing surfaces of permanent molar teeth through appropriate school-based programs and through adequately funded government programs for these services.
2. Increase the number of high-risk children receiving dental screenings and referrals to dentists for care.
3. Increase the number of Coloradans served by fluoridated community water systems with optimal levels of fluoride.
4. Advocate for more data collection and surveillance by the appropriate state agencies to determine the oral health status of Coloradans, especially children.
• Oral Health Literacy:
1. Educate children and parents on the importance of good oral health, how to have good oral health, and the importance of seeing a dentist.
2. Educate Coloradans on the importance of annual oral cancer examinations performed by a dentist and educate Coloradans on the dangers of tobacco use as it pertains to oral cancer.
3. Develop educational materials (written, visual, mixed media) that are at the appropriate education level and are culturally and linguistically appropriate for the target audience.
4. Pursue development of a comprehensive oral health education component for public schools’ health curricula in addition to providing editorial and consultative services to primary and secondary school textbook publishers.[9] Target the at-risk groups first – poor children, racial and ethnic minorities, the elderly, rural residents, and individuals with disabilities or other special needs.
5. Provide information to dentists and their staffs on cultural diversity issues which will help them to reduce or eliminate barriers to clear communication and enhance understanding of treatment and treatment options.[10]
6. Form collaborations and partnerships with other interested groups to develop and disseminate oral health education materials. Possible groups include community-based health centers, public health clinics, area health education centers, K-12 school systems, and hospitals among others. Promote the Dental Home concept.
7. Improve patient education and counseling in the dental office environment to help increase dental knowledge in patients with low oral health literacy levels.
8. Change perceptions of oral health by explaining in the simplest terms why oral health is important and what simple steps individuals can take to preserve their own oral health and that of their children, as well as recognize possible signs of trouble and when to seek out care.
9. Engage populations and community organizations in the development of health promotion and health literacy action plans.
10. Encourage more interdisciplinary collaboration and care among health care providers to manage the health-oral health of each person.
11. Encourage greater utilization of currently available resources for oral health, such as the Oral Health Literacy:An Annotated Bibliography of Materials for People with Limited Literacy Skills. ()
• Utilization:
1. Initiate appropriate recruitment efforts to increase the numbers of under-represented minority, disadvantaged and rural-area students in dental schools.
2. Encourage providers to increase their cultural competency to create trust and comfort, thereby influencing utilization of oral health care.
3. Work with the federal and state governments to provide additional financial incentives for dentists to provide regular care in underserved areas.
• Workforce:
1. The CDA Workforce Committee should continue to monitor Colorado’s Dental Health Professional Shortage Area (DHPSA) designations and report inaccuracies so that the need for additional dentists is reported accurately and not exaggerated.
2. Advocate for solutions for access to care based on correct data and assumptions utilizing the experience of dental practitioners rather than the medical model or under-trained providers.
3. Continue to monitor business trends that can impact the dental delivery system and educate dentists about opportunities to streamline and obtain economies of scale without compromising the quality of patient care.
4. Educate dentists in ways to maximize the use of the current workforce while maintaining dentist supervision.
5. Explore innovative ways to expand the capacity in current dental practices.
6. Encourage the University of Colorado’s School of Dental Medicine to continue collaborating with those states without a dental school to assist with meeting workforce needs.
7. Advocate for more loan forgiveness programs or monetary incentives that are tied to the dentist providing treatment in underserved areas.
8. Advocate for a state and federal tax deduction for dentists who provide well-documented free care to the indigent and low income populations.
9. Establish a program with the University of Colorado’s School of Dental Medicine to evaluate how curriculum, recruitment and financial options could best be structured to provide for access needs in rural and underserved areas.
10. Advocate for resource grants and gifts to supplement the cost of dental education for those students willing to practice for four years in a designated area of need.
11. Advocate for DHPSA sites to become National Health Service Corps sites for loan forgiveness/repayment for new graduates.
12. Advocate for HRSA to evaluate and investigate DHPSA classifications so that funding of dental health care needs is based on accurate data.
13. Encourage the University of Colorado’s School of Dental Medicine to structure General Practice Residency programs to encourage and target dental school residents for rural access slots of need.
• Government Programs:
1. Advocate for adult dental benefits in Medicaid that include preventative and critical restorative services, with priority given to the aged, blind and disabled.
2. Advocate for government programs to streamline administration of the Medicaid and CHP+ programs.
3. Advocate for the government to provide adequate funding of public dental programs.
4. Advocate to prevent Dental Management Organizations from closing panels and limiting access to government funded programs. Require DMOs to re-open the closed provider panels in the CHP+ program to allow more providers in the network to see the patients seeking care.
5. Advocate for increased funding for Public Health (e.g., school based programs, loan forgiveness, fluoridation, etc.) that includes a plan on the most efficient use of the dollars.
6. To encourage Medicaid provider participation, simplify the credentialing process for dental providers by allowing applications to be completed online in their entirety. Currently .... [consult with Medicaid providers on the process works in Colorado.] Providers should only have to go through the credentialing process one time.
7. Streamline the Medicaid and CHP+ paperwork and claims processes to more closely mirror private sector plans. Reduce the number of Medicaid/CHP+ procedures that require pre-authorizations.
8. Monitor the evolving health care reform legislation and advocate for appropriate dental benefits for children.
• Financing Care:
1. Encourage a higher maximum dental benefit and the elimination of waiting periods and pre-existing clauses in all private dental insurance plans.
2. Encourage employers to consider a direct reimbursement model to allow the employer and the employee to be more actively involved in dental health decisions.
3. Encourage the increased use of flexible spending accounts for dental care.
4. Encourage offices to be flexible with payment plans or to utilize the services of companies that provide financing services (with interest) for patient treatment to open treatment for more individuals.
5. Advocate that dental reimbursement fees for the Medicaid and CHP+ dental program be evaluated on a regular basis and that fees be established that are more competitive with market fees.
6. Adequately fund the Medicaid and CHP+ programs through state and federal funding.
7. Offer incentives to dentists to establish practices in rural, underserved areas of the state by providing sales tax breaks for the purchase of equipment necessary to set up a dental practice and/or to build a practice.
• Safety Net:
1. Recognize the importance of oral health to overall health by providing adequate funding to maintain the public health safety net that provides much-need prevention services to Colorado's children.
2. Increase starting and mid-point salaries for public health dentists and dental hygienists to the current maximum salaries.
3. Provide funding to expand dental clinics in all Federally Qualified Health Centers; encourage competitive salaries for dentists and dental hygienists to attract providers.
4. Continue to collaborate with stakeholders to maintain and to establish additional programs that are community-based solutions to access to care.
• Innovative Outreach:
1. Consider legislation that would provide state tax credits for donated dental services provided in volunteer clinics.
2. In communities where the population cannot support a dental practice, mobile dental vans could be an alternative for care.
3. Teledentistry is an emerging technology. Therefore, the CDA believes that appropriate oversight and regulations should be in place to assure patient safety.
INTRODUCTION
Oral health is not only important for a healthy mouth, it is also important for overall health. The ability to access dental care is an essential element of a healthy population. Dentistry is a prevention-based profession and most dental disease can be eliminated or dramatically improved by seeing a dentist regularly. For every dollar spent on prevention there is a four dollar savings in treatment costs.[11] However, many Coloradans do not understand the importance of seeking dental care. Numerous people purchase dental care with discretionary dollars and do not always see the importance of making oral health a priority in their personal budgets. Employer dental benefit plans have not kept up with the cost of care and many plans fail to pay first dollar coverage for preventive services. Some individuals have difficulty accessing the system because inadequate funding of government programs limits dentists,’ as the programs do not even cover the cost of providing the services. Others can experience barriers such as transportation, literacy, cultural issues, to cite a few.
Of the 5 million people living in Colorado, 42 percent of adults reported not having dental insurance,[12] and an estimated 30.5 percent of Colorado children are without coverage.[13] Medicare, the primary source of medical coverage for seniors, does not include dental benefits, and, for adults, Colorado Medicaid covers only emergency dental procedures or those that are directly related to a concurrent medical condition.[14] Only 30 percent of seniors over age 65 have any type of dental insurance.[15] The number of Medicaid clients in Colorado has nearly doubled over the past decade, to 500,000 people in 2009. [16] In total, almost half of Colorado's population has no dental benefit and self-pays for dental services.[17] Most dental insurance is purchased through employers and very few stand-alone dental plans exist. The plans that do exist are generally not competitively priced based on the benefits they provide. Requiring insurance companies to offer a stand-alone competitively priced dental plan that covers preventive services could increase access to care and improve the oral health status of Coloradans. Increased access to dental care could potentially save unnecessary costs incurred by patients seeking care from hospital emergency rooms and physicians who can only treat the symptoms of dental disease, not the underlying cause.
Coloradans who utilize dental care enjoy the highest quality of care in the world. It is the goal of the Colorado Dental Association for all Coloradans to have access to dental care. The CDA is a leading proponent of educating Coloradans on the need to seek dental care. In addition, it is estimated that Colorado dentists provide $10-15 million annually in donated dental care through private offices and volunteer-staffed dental clinics. A recent survey of Colorado’s urban dentists reported that over 90% of Colorado dentists provided charity care in 2008.[18]
While the profession has enjoyed great successes in increasing access to dental care for Coloradans, there is still much that needs to be done. The dental profession is eager to work with private groups, government entities, community organizations, teaching facilities and public health entities to help Coloradans understand the need for regular dental care and to have access to that care. The following document outlines some of the current delivery system strengths and the challenges we need to address to reach optimal oral health for every Coloradan. We encourage those who are interested to work with the Colorado Dental Association to make Coloradans number one in optimal oral health.
DEFINITIONS
Access to care -“The ability of an individual to obtain dental care, recognizing and addressing the unique barriers encountered by an individual seeking dental care, including the patient’s perceived need for care, oral health literacy, dentist and dental team distribution, financial circumstances, special needs, transportation, location, language, cultural preferences and other factors influencing entry into the dental care system.”[19]
Dental Management Organizations (DMOs) – A private organization that has entered into a risk-based contractual arrangement to obtain and finance care. Does Delta qualify as a DMO in its administration of CHP+? If not, do we need this definition?
Dental Health Professional Shortage Area (DHPSA) –The U.S. Health Resources and Services Administration Shortage Designation Branch develops dental shortage designation criteria and uses them to decide whether or not a geographic area, population group or facility is a Dental Health Professional Shortage Area. Many federal programs depend on this designation to determine eligibility for funding (i.e., National Health Service Corps scholarship and loan repayment program, Area Health Education Centers, cost-based reimbursement for Federal Qualified Health Centers).
Federally Qualified Health Centers (FQHCs) –A community-based organization that provides comprehensive primary care and preventive care, including oral health care, to persons of all ages, regardless of their ability to pay. Services utilize a sliding fee scale with discounts based on family size and income.
Mid-level Dental Provider (MLP) –An oral health care provider whose training and responsibilities would fall between those of a dental assistant and those of a licensed dentist and may be allowed to diagnose and perform irreversible procedures with less education than a dentist.
Utilization of Oral Health Care Services – “The percentage of the population receiving oral health care services through attendance to oral health care providers, while taking into consideration factors including, but not limited to, health-related behaviors, oral health literacy, dentist and dental team distribution, financial circumstances, special needs, transportation, location, language, cultural preferences and other factors influencing entry into the dental care system.”[20]
DISCUSSION
Numerous components impact Coloradans ability to access dental care: health status, oral health literacy, utilization, workforce, financing care, government programs, safety net, innovative outreach, and external influences. Where possible, the following discussion portrays Colorado-specific data and information.
Health Status:
Subcommittee assignment: Review CDPHE 2005 report and oral health snapshot to decide which are the most relevant statistics to include
In Colorado – as in most states, data collection on oral health issues is limited by ongoing budgetary constraints and research must rely on periodic assessments of oral health status. The most recent comprehensive report is from the Colorado Department of Public Health and Environment’s (CDPHE) 2005 report, “The Impact of Oral Disease on the Health of Coloradans.”[21] Oral health is critical to overall health and must receive the same attention and resources as medicine. According to the 2000 Surgeon General’s Report, dental caries is identified as the most common chronic disease of childhood, five times more common than asthma.[22]
Colorado's oral health has improved tremendously in the last 50 years, yet there is still more improvement that needs to take place. The oral health of Coloradans does yet not meet the Healthy People 2010 objectives set by the U.S. Department of Health and Human Services.
Dental caries (cavities), both untreated and treated, have a major impact on young children. According to the CDPHE Oral Disease Impact report, low income children are affected more than affluent children. [23] Hispanic children and other minority populations are affected more than White children.[24] Over one-quarter (26%) of third graders in Colorado have untreated dental caries, although over three-quarters of children (79%) have been seen by a dentist in the past year.[25] The oral health of adults in the state of Colorado is also a concern. In 2005, only two-thirds of Colorado of adults visited a dentist or a dental clinic in the past year. Significant oral health disparities exist with regard to race and ethnicity, as well as income and education.[26]
Cancer of the oral cavity or pharynx is the fourth most common cancer in Black males and the seventh most common cancer in White males in the U.S.[27] Per the CDPHE report,[28] Colorado’s oral cancer rates appear to lower than most national statistics. Males have a higher incidence of oral cancer than females. The use of alcohol and tobacco is a contributing factor to oral cancer. Early stage of disease detection is a significant key to oral cancer survival. Minority groups are significantly less likely to receive early diagnosis than Whites in Colorado.
Water fluoridation helps to reduce the caries rate in children and adults. People are faced with more and more amounts of refined carbohydrates (sugars) in their diet. Optimally fluoridated water helps combat these increases of sugar in our diet and has been praised by the Centers for Disease Control and Prevention as one of the greatest public health measures of the 20th century. Colorado is fortunate to have many water supplies with naturally optimal (0.9–1.1 parts per million) levels of fluoride serving 14% of the population.[29] Numerous additional communities adjust their fluoride levels, bringing the total population using community water systems with optimal fluoride to over 75% (or almost 4 million people).[30]
Oral Health Literacy:
Oral health literacy as defined by the U. S. Department of Health and Human Services in Healthy People 2010 is “the degree to which individuals have the capacity to obtain, process and understand basic oral and craniofacial health information and services needed to make appropriate health decisions.”[31] Low oral health literacy can affect any population group and can have a significant impact on a person’s ability to understand instructions being given by the dentist or hygienist, difficulty understanding instructions on prescription bottles, appointment slips, or educational brochures affect their ability to seek out needed health information, as well as their ability to make appropriate health care decisions.
The average American reads at an eighth or ninth grade level. However, most health information is written at a higher reading level.[32] Limited literacy skills have been found to be a stronger predictor of an individual’s health status more so than other common factors, such as race, ethnicity, age, income or education level.[33] Limited health literacy has been estimated to cost the U.S. between $100 and $200 billion each year.[34]
Increasing oral health literacy will take a concentrated effort. A good start at raising the dental IQ of our nation could be accomplished by targeting the two most significant circles of influence of our young people – schools and parents. It is critical to place accurate information about oral health into the school curriculum and reinforce this with information to help parents understand and support oral health education in the home. Educating parents on the dangers of carbonated beverages, sports drinks and processed sugars as well as how to properly teach a child to brush and floss is critical. Helping parents and educators to raise a generation that has good oral health is beneficial to our society and future generations of children.
Utilization:
Utilization of dental care is affected by potential barriers that are unique to each patient. Barriers can include insurance status, financial resources, education and transportation, geographic limitations, a patient’s age, cultural background and fear of dental procedures. According to a 2002 Behavioral Risk Factor Surveillance System survey, of the 33% of Coloradans had not visited the dentist during the year 40% responded that they did not see a reason to go, while only 26% stated cost as the primary reason. Other reasons included fear and pain, and not having a dentist.[35]
As discussed above, a patient’s income plays a large role in whether he or she seeks dental care. When family income was 200% to 400% of the federal poverty level, 41.9% of families had at least one dental visit whereas only 26.5% of families whose income was 100% or less of the federal poverty level had at least one dental visit.[36] Children from high-income families were twice as likely to have a dental visit as poor children.[37]
Of the 5 million people living in Colorado, 42 percent of adults reported not having dental insurance,[38] and an estimated 30.5 percent of Colorado children are without coverage.[39] The number of Medicaid clients in Colorado has nearly doubled over the past decade, to 500,000 people in 2009. [40] Medicaid serves 19 percent of all children in Colorado. [41] Colorado provides comprehensive dental benefits to Medicaid-eligible children under 18 but only provides emergency coverage for eligible adults. Federal regulations make a child ineligible for Medicaid if the child’s parent is a state employee.[42] State employees may be unable to afford dental insurance for their children yet the children of state employees are also denied access to CHP+ coverage. Some people speculate that as more than half the state employees in Colorado would be eligible for Medicaid or CHP+ based on income.
While the older demographic has one of the greatest needs for dental care, they often have the fewest resources to obtain treatment. The elderly currently have little or no safety net for dental care. Government assistance is virtually non-existent and the facilities in which much of the older population resides, residential or nursing homes, often do not provide regular dental care for residents and may not provide transportation for off-site dental care.[43] Medicare, the primary source of medical coverage for seniors, does not include dental benefits.[44] Only 30 percent of seniors over age 65 have any type of dental insurance.[45] Colorado statistics show that dental visits drop off substantially after age 55. 71% of adults ages 45-64 had a least one dental visit during 1999, compared to only 64% of older adults (ages 65 and older).[46] National statistics are even more startling, showing a trend of only 49% of adults (age 45-64) and 43% of older adults (age 65 and older) having a least one dental visit during 2004.[47] However, financial constraints are clearly not the only barrier to utilization as, for children whose dental care is paid in full by Medicaid in Colorado, only about 40% received dental care in 2007. [48]
Education and oral health literacy can also have a significant impact on a person’s ability to seek needed health information and to make appropriate health care decisions. The higher the individual’s education level, the more likely they are to have at least one dental visit. In fact, 54.5% of college graduates went to a dentist at least once as compared to only 21.9% of individuals with some or no school having a dental visit.[49] In Colorado, college graduates were 50% more likely to have visited a dentist in the past year compared to those who did not graduate from high school.[50]
Cultural barriers can be a significant obstacle to care. While Colorado’s Hispanic population is growing quickly (currently representing almost 20% of all Coloradoans)[51], Hispanic dentists comprise only 4.1% of actively practicing dentists nationwide.[52] Colorado’s averages are slightly higher with Hispanic dentists comprising 4.3% of urban and 6.5% of rural dentists in the state.[53] A survey of Latino parents revealed that language issues were cited as the single greatest barrier to health care access for their children.[54]
Many organizations have proposed to solve the access to care issue by creating new types of non-dentist, mid-level providers to treat patients or by expanding the services an existing dental auxiliary can provide with reduced or no supervision from a dentist. Neither of these approaches has been successful.
Colorado sought to increase access by allowing dental hygienists to have independent practice. Stand-alone dental hygiene offices had the same expenses for equipment, supplies and office space as dental offices and thus relatively comparable fees for preventive dental services. As a result, most of these independent hygiene practices were located in affluent or middle-income areas where their potential effect on access to care for the underserved was inconsequential.[55] It is possible that the independent practice of dental hygiene increased the overall cost of dental care and created a convenience issue when the patient could not access dental hygiene services and dental restorative services at the same time.
In New Zealand and Canada a new type of dental provider, called the dental health aid therapist (DHAT), was created. New Zealand attempted to utilize the DHAT to provide free care to all children. This proved to be financially unsustainable. According to New Zealand’s Ministry of Health, there continues to be pockets of children with oral disease at the level of developing or Eastern European countries.[56] Canada also had little success with the DHAT. With only two years of dental training, the salaries for these mid-level dental providers were inadequate to entice them to practice in the remote areas where access is a problem.[57] Efforts to increase access to care must be diverse to address the many barriers to care that exist. Merely creating different types of mid-level providers has proven to be ineffective.
Workforce:
Subcommittee assignment: review relevant dental workforce publications and expand this section to address the full workforce discussion in Colorado
An adequate workforce is a key element in providing access to dental care. The determination of an adequate workforce is more than the number of dentists or dental auxiliaries within a state. From a workforce perspective, adequate access is affected by the following: the geographic distribution of dentists and dental auxiliaries; the availability of specialty practitioners; and the number of dentists that participate in government programs. As discussed in this section, the current workforce number is adequate and the plan is in place to expand to meet the workforce needs in Colorado as the population increases.
Other factors that influence the ability to maintain and recruit an adequate workforce can be directly related to having a dental school within the state, the number of dental hygiene and dental assisting training programs, the ability of a community to provide economic viability for a dental practice as well as the quality of life that can be offered to the practitioner. Any new category of provider will be faced with the same influences that create dentist shortages in certain areas and communities. It is impossible to alleviate distribution shortages solely by adding a new category of dental provider, such as the mid-level provider.
According to the CDC, over 3,400 dentists are actively practicing in Colorado or 7 dentists per 10,000. [58] Therefore, Colorado should have an adequate number of dentists based on the 1:3,000 dentist-to-population ratio recommended by the federal Health Resources and Services Administration (HRSA) to meet current demand for dental care.[59] Colorado is ranked sixth highest in dentists per capita in the nation.[60]
According to the CDC, over 4,500 dentists hold an active license to practice in Colorado. Of that number, about 1,000 dentists have a Colorado license but live or practice in another state. Colorado-licensed practitioners hail from all 50 states, U.S. territories and international countries.[61] Colorado licenses approximately more than 250 additional dentists each year.[62]
Colorado has one dental school that graduates 52 dentists annually and since 1977. The University of Colorado’s School of Dental Medicine recently announced that it will increase dental school admissions by just over 50% starting in 2011, with a 2011 freshman class of 80 students. This should yield a substantial increase to the dental workforce in Colorado by 2015. The University of Colorado’s School of Dental Medicine currently offers about 25 advanced dental education residency slots for specialty areas and general dentists (2 in periodontics, 16 in orthodontics, and 6-7 in the general practice residency program). The University of Colorado School of Dental Medicine has awarded approximately 1,116 dentistry degrees since its inception. Although it is not possible to know exactly how many dentists trained in Colorado practice or ever practiced in the state after graduation, data indicates that approximately 50% of dentists trained in Colorado were practicing in the state in 2008 and 2009. While available literature on dental graduate retention is limited, Colorado’s retention rate appears to compare favorably with those of other states.[63]
Discuss education system challenges – funding, shortage of professors, etc.?
Colorado's age demographics are favorable for a stable and growing workforce. About 37% percent of Colorado's actively practicing dentists are 55 or older. Of that number only 10% are over the age of 65. Almost 63% percent of practicing dentists are under the age of 55 and the mean age is 49.7 years.[64] Considering that 29 is the average age of graduation from dental school[65], the average dental career is 30-35 years long, [66] and as many as 75% of dentists report that they plan to continue to practice at least part-time after “retirement,” [67] these demographics suggest a vibrant work force for the next 20 years.
In recent years the dentists’ participation in government funded programs, specifically Medicaid, decreased dramatically. Currently, about one-fifth of dentists in both urban and rural Colorado report accepting Medicaid patients in their practices. [68] Analysis of Medicaid acceptance rates for general dentists versus specialists reveal no appreciable differences. [69] Studies in the available literature suggest that acceptance rates of Medicaid reimbursement are relatively low nationwide.[70] Data shows that Colorado dentists are almost twice as likely to accept CHP+ patients than Medicaid.[71]
Data substantiate that a large segment of the dental community was willing to provide care to this patient population prior to decreases in Medicaid reimbursement levels and increased administrative burdens, like excessive audits and difficult claims filing systems, in the early to mid 2000s. Draconian cuts in Medicaid reimbursements have forced hundreds of dentists out of the program. A program that had over 530 participating dentists in 2003 lost almost 30% of its providers in just over 5 years, with less than 400 dentists participating by 2009. Of the near 400 dentists in the program in 2009, fewer than 5% of dentists (or 19 providers) would be classified as “significant providers” treating more than 50% of all the patients who receive care.[72] When inadequate funding and difficulties in administration evolve, inadequate numbers of providers result thereby compromising access to care.
2008 and 2009 surveys of rural and urban Colorado dentists asked all dentists who reported that they did not accept Medicaid patients to indicate their reasons for not doing so. Low reimbursement was the most common reason for lack of participation. [73] Other reasons dentists cite for not accepting Medicaid enrollees parallel those cited across the country and include low reimbursement rates, patient non-compliance and broken and no-show appointments.[74] Dentists also were asked to rate how important they thought certain policies would be in improving access to oral health care in Colorado. Increasing Medicaid reimbursement was rated important by nearly 75 percent of responding dentists, followed by ensuring the availability of loan forgiveness programs for dentists willing to practice in underserved areas (62%).[75] Dentists’ responses to this question suggest that increasing Medicaid reimbursement rates or expanding loan forgiveness programs may be effective policy options to pursue in the long term to improve Medicaid acceptance rates.[76]
In 2007, the Center for Studying Health System Change found that among the range of health care services offered, oral health care was the most difficult to obtain for low-income individuals, largely attributable to the small number of dentists willing to accept public insurance. [77] The Center found that the tendency for dentists to decline participation in publicly financed programs was linked to student debt after dental school, at that time averaging $162,155, and the overhead costs involved in running a private dental practice which averaged 60 cents for every dollar earned. [78] Dentists routinely state that low Medicaid reimbursement rates make it particularly challenging financially to serve Medicaid patients.
The perception of poor program participation by dental providers may be exaggerated by the lack of an adult Medicaid benefit. Not all dental offices provide care to children; thus, the pool of possible providers is not equal to the number of dentists practicing in Colorado. There are many specialty practices – such as prosthodontics and periodontics – that serve almost exclusively adult populations. Some general dentists are not comfortable treating children or children under a certain age. Children are a very small percentage of the population served in other dental practices, and some offices would rather provide care for free than face the perceived burdens and limitations of enrolling in the Medicaid program and learning the associated processes and systems. In fact, thanks in large part to targeted recruitment campaigns, pediatric dental practices in Colorado participate in Medicaid at a higher rate than dentists as a whole. While there is vast opportunity for improving provider participation and these efforts should certainly be pursued, care should be taken to consider the factors outlined above and recruitment efforts should be designed to target the provider populations most likely to participate.
Further, Colorado is primarily a rural state, with 80 percent of its population residing in 10 metropolitan counties on the eastern side of the Rocky Mountains, known as the “front range.” Twenty-three of Colorado’s 64 counties are frontier (less than six people per square mile) and an additional 24 counties are rural. The distribution of dentists is concentrated along the Front Range, in the major population centers. While some predominantly rural counties have a higher than average dentist-to-population ratio, a number of these counties nevertheless may be underserved because of geographic or economic barriers to access.[79] Rural and frontier populations may face substantial travel distances to obtain dental care. Also known as the “highest” state because of its altitude, Colorado’s numerous mountain passes often create geographical barriers in accessing oral health care services.[80] Latest figures indicate that there are 9 counties in Colorado without a dentist[81] and around a dozen without a dental hygienist.[82] However, many counties have population numbers (10,000 or less) that make it difficult to sustain a dental or dental hygiene practice. The economic viability of maintaining a practice may preclude dentists and dental hygienists from locating in some of these rural and frontier communities. Access to a dentist is within a reasonable drive time for many residents of these rural counties. Commercial mobile vans also provide access to care for many of the counties listed as not having a dentist. Although the state department of public health in general has taken huge budget hits, the dental program continues to provide some preventive services in rural areas, such as school-based varnish and sealant programs for children. Further, there are 69 community-based low-income dental clinics (how many in rural areas?), 4 local health departments that provide dental services (are all rural?) and around 10 public health mobile vans.[83]
According CDC data, approximately 3,900 dental hygienists held an active Colorado dental hygiene license in 2009. [84] Of these, 3,000 were practicing in Colorado. There is no definitive information the supervised versus unsupervised practice of licensed hygienists or the number of hours worked in each capacity. Dental hygienists render a valuable service and are an integral part of the dental team. Their skills are meant to be applied in concert with the broad skills and knowledge of the dentist. As part of the umbrella of care, dental hygienists improve access to care.
Colorado currently has 3 dental hygiene programs, which graduate approximately 66 hygienists annually. [85] The only program in Colorado offering a bachelor’s degree in dental hygiene, the University of Colorado Denver School of Dental Hygiene, stopped admitting students in 2007, at which time 20 students were admitted into the program each year. Recent economic pressures have resulted in cuts to many bachelors level dental hygiene programs around the nation. Currently, only 13 percent of entry-level dental hygiene programs offer a bachelor’s degree. [86] Many of Colorado’s dental hygienists are educated in other states, as data indicates that only 60 percent of Colorado’s dental hygienists are educated in Colorado. [87] Anecdotally, the CDA staff is hearing from the hygiene educators that a significant number of graduates are having difficulty finding jobs given the current economy.
Age demographics among Colorado’s dental hygienists also are favorable for a stable and growing workforce. Only 17% percent of Colorado's practicing dental hygienists in 2006 were 55 or older. Of that number only 1% are over the age of 65. Over 83% percent of practicing dentists are under the age of 55 and most dental hygienists were mid-career with an average age of 45 years. [88] The Colorado Department of Labor projects growth at three times the market rate for the dental hygienist workforce in Colorado at least through 2019. [89] These demographics suggest a vibrant work force for the next 20 years.
In 2001, Colorado state law was changed to allow unsupervised dental hygienists in Colorado to directly bill for Medicaid allowable services. However, a majority of dental hygienists, like dentists, did not accept Medicaid patients. [90]
There has been no report of a shortage of dental assistants in Colorado. Dental assistants are not licensed in Colorado and state law is broad on the duties dental assistants can perform under a dentist’s supervision. Their training can be accomplished on the job or through any of the 5 dental assisting programs in the state, [91] which train slightly more than 100 graduates per year. [92] The Colorado Department of Labor estimates that there were over 5,800 dental assistants employed in Colorado in 2009 (a ratio of almost 2 assistants per dentist, which is slightly higher than the national average). [93] The Colorado Department of Labor also projects growth at three times the market rate for the dental assistant workforce in Colorado at least through 2019. [94]
The process of designating Dental Health Professional Shortage Areas (DHPSAs) has implications for access to care and proposed solutions to addressing access to care. In Colorado, the state Primary Care Office works with the Bureau of Health Professions in the federal Health Resources and Services Administration to designate counties and/or specific census tracts as dental Health Professional Shortage Areas (DHPSA). In order for an area to be designated as a DHPSA, one of the following criteria must be met: 1) a dentist-to-population ratio of 1:5,000 or greater; or 2) a dentist-to-population ratio of 1:4,000 or greater in areas with less than half the population on fluoridated water or where greater than 20 percent of the population is at 200 percent or below the federal poverty level. [95] As of July 2010, there are 21 counties (including 3 partial counties) designated as geographic DHPSAs and 23 counties (including 3 partial counties) with designated low-income DHPSAs in Colorado. [96] The number of DHPSAs has expanded substantially in Colorado since 2005, when only 20 total counties (including 6 partial counties) were designated as either geographic or low-income DHPSAs. [97]
Once an area has a DHPSA designation, the community has expanded tools and opportunities to help recruit oral health professionals to these rural and underserved areas. Designation as a DHPSA ensures eligibility for more than 34 federal programs including the National Health Service Corps, scholarship funds and loan repayment. Additional tools available to rural communities include state tax credit programs, low-cost loans for establishing a dental practice from a local bank, real estate assistance in finding a practice site and securing loan assistance, and entry into local community support systems such as the local school board and school superintendent’s office, recreational opportunities, local cultural events and other services that characterize the community’s unique resources and assets. Oral health recruitment in DPHSAs is a community activity that requires the commitment of the entire community. [98]
Originally DHPSA designations were based on supply – with a goal of encouraging dentists to practice in remote locations. Over time they have evolved into designations that are based on access – with a goal of addressing the population’s economic need. However, the nomenclature describing the shortage areas has not been modified to reflect this change. Consequently, the nomenclature is perhaps misleading in implying that simple solutions (simply a greater number of dentists and/or expanded scopes of service) can solve a highly complex issue. The nomenclature does not address the intricate issues related to access to dental care (economics, oral health literacy, cultural barriers, transportation, etc.). Further, the number of DHPSAs has increased dramatically to the point that the designation may no longer predictably target the areas of greatest dental under-service and may exaggerate the need for additional dentists in some cases.
Following the medical model is not the solution to access. Like most other states, Colorado is experiencing a significant shortage of primary care physicians. Yet, the medical community continues to struggle with access to primary medical care despite having created a plethora of non-physician primary care clinicians (NPCCs), such as physician assistants (PAs), nurse practitioners (NPs) and certified nurse midwives (CNMs). NPCCs have not alleviated the mal-distribution or shortage in certain areas. In fact, the use of NPCCs may have had a negative impact on the ability to recruit and train more physicians.
Further, there are distinct differences between the delivery of dental and medical treatment. Dental care delivery and financing systems emphasize prevention, primary care, cost containment and administrative efficiency. Approximately 80% of all dentists are generalists, compared to 40% in medicine.[99] Dentistry does not compete for the health care dollar; it usually vies for the discretionary dollar. Because of these differences, medical model solutions should not be artificially imposed onto the dental model.
The following excerpt is taken from the Academy of General Dentistry’s White Paper on Access to Care:[100] “One might contend that independent mid-level providers in medicine, such as advanced nurse practitioners, have benefited the health care system. However, independent mid-level providers in dentistry and advanced nurse practitioners differ fundamentally in the models by which they practice, or intend to practice… The medical model is driven by a first diagnosis at the patient’s ‘point of entry,’ and often a second or third diagnosis based upon the direction of referral. On the other hand, dentistry has served its patients quite well through the prevention-based ‘dental team concept’ rather than a ‘point of entry’ concept. The dental team concept serves the function of dentistry and patients’ access to care with its focus not merely on diagnosis of dental diseases, but rather on prevention and continuity of care through treatment. That is, in dentistry , the ‘point of entry’ is the point of prevention and treatment—it is not just a segue to further diagnosis and possible intervention—thereby saving both time and cost.”
Financing Care:
A patient’s decision to seek dental care often depends on who pays for the care. Dental care financing options include Government Health Insurance Programs for those that qualify, such as Medicaid and CHP+; Private Insurance/Private Coverage including employer sponsored dental insurance (HMO, PPO), indemnity plans, discount dental plans, and direct reimbursement plans; and private pay.
According to a publication by the Colorado Health Institute, approximately 40% of Coloradans were dentally uninsured in 2008-2009.[101] Of the 5 million people living in Colorado, 42 percent of adults reported not having dental insurance,[102] and an estimated 30.5 percent of Colorado children are without coverage.[103] Many Coloradans who report having no dental insurance may be otherwise covered by health insurance, including publicly financed health insurance programs such as Medicaid, Medicare and Child Health Plan Plus (CHP+). In fact, only 14-16% of Coloradans were reported to be medically uninsured in 2008-2009. [104],[105]
Government Programs include Medicare, Medicaid and SCHIP plans. Medicare, the primary source of medical coverage for seniors, does not include dental benefits, except for those that are an integral part of a covered medical procedure. 10% of Coloradans were covered by Medicare in 2008-2009 [106] and only 30 percent of seniors over age 65 have any type of dental insurance.[107] The aging of Colorado’s population will continue to present challenges for dentistry. Increased life expectancy, aging of the baby boomers and decreasing rates of tooth loss among older adults is likely to produce a greater demand for oral health care services as the population ages. Between 2010 and 2030, the number of Coloradans age 65 and older is projected to more than double—while the proportion of individuals age 65 and older relative to the population is expected to increase from 10 percent of the population to18 percent. [108] National statistics parallel those in Colorado. People 65+ represented 12.4% of the population in the year 2000 but are expected to grow to be 19% of the population by 2030.[109] Many will remain in the workforce longer. However, they will present greater health care demands, including demand for dental care. The dental care delivery system must prepare for to meet these anticipated demands.
Medicaid is available to Colorado’s low income populations. The Colorado Healthcare Affordability Act of 2009 (HB 09-1293) expanded Medicaid eligibility in Colorado to parents in families with incomes up to 100 percent of Federal Poverty Level (FPL). In addition, the legislation created two new adult eligibility categories: one for adults who are not parents of dependent children (heretofore referred to as childless adults) at or below 100 percent of FPL and another for adults with disabilities whose incomes are at or below 450 percent of FPL who can buy into the Medicaid program (implementation begins winter 2012). [110] Prior to this bill, adults who were not parents or are not disabled could not get Medicaid, no matter how poor they were. Working parents had to make less than 66 percent of the FPL to qualify for Medicaid. [111] Even still, adults with Medicaid in Colorado may be required pay some of the costs of their health care out of their own pocket. [112] Adults covered by Medicaid do not have an oral health benefit except emergency dental procedures or if there is a directly related concurrent medical condition that necessitates providing dental treatment. [113] The total number of Medicaid clients in Colorado has nearly doubled over the past decade, to 500,000 people – or about 10% of Coloradans – in 2009. [114]
Medicaid coverage for Colorado children is broader. Federal healthcare reform passed in March 2010, the Patient Protection and Affordable Care Act (HR 3590), expands Medicaid eligibility to children up to 133 percent of FPL who meet the citizenship eligibility requirements . [115] In Colorado, Medicaid dental benefits are available for children under age 21. Medicaid covers most standard preventive and restorative services for children. Medicaid serves 19 percent of all children in Colorado. [116] Combined, the Medicaid and CHP+ programs provided publicly financed health insurance to more than 276,000 low-income children in Colorado in 2008. [117]
CHP+ provides comprehensive healthcare services, including some dental benefits, to Colorado children under age 18 and pregnant women 19 and over who meet certain income requirements. To qualify for CHP+, the child or pregnant adult must be a U.S. citizen and Colorado resident, uninsured and not eligible for Medicaid. Families on CHP+ may be required pay some enrollment fees or co-pays on a sliding scale based on family income. [118] As of December 2009, the CHP+ program covered 70,000 children and pregnant women. [119] The Colorado Healthcare Affordability Act of 2009 (HB 09-1293) expanded eligibility in CHP+ to include children in families up to and including 250 percent of the FPL.[120] Previously the program covered children up to 205 percent of FPL. [121] This expansion will add almost 12,000 children to public coverage should all be enrolled. [122] CHP+ provides a limited dental benefit up to $600 per year that includes exams and cleanings, fillings, extractions and some root canals for enrolled low-income children.
While state-financed healthcare is a large part of the annual state budget, dental Medicaid and CHP+ for kids represent a very small percentage of the annual state budget. For years, Medicaid has accounted for approximately one-fifth of Colorado’s state budget. [123] The total Medicaid budget request for fiscal year 2009-10 was over $4 billion or approximately 21.1% of the state’s total budget.[124] However, in 2008-09, total Medicaid dental expenditures were $88.7 million[125] and CHP+ expenditures were just under $10 million.[126] In 2008-09, the total Colorado state budget was $18.4 million; [127] thus, the cumulative $100 million spent by the state on publicly financed dental programs equates to less than 0.5% of the state budget.
Federal regulations make a child ineligible for Medicaid if the child’s parent is a state employee.[128] State employees may be unable to afford dental insurance for their children yet the children of state employees are also denied access to CHP+ coverage. Some people speculate that as more than half the state employees in Colorado would be eligible for Medicaid or CHP+ based on income.
Multiple options are available for private dental insurance. Health Maintenance Organizations (HMOs) offer dental plans that require the individual to choose a dentist from a limited list of providers. These plans contract with dentists to be paid at a capitated rate and the patient pays a copayment at the time of service. The premium for these plans is generally lower than Preferred Provider Plans (PPOs). PPO dental plans allow the individual to choose from a larger list of providers and allow for more freedom in their treatment; providers contract to be paid at discounted rates by service code. Indemnity plans provide the freedom of choice of dentist but has higher out-of-pocket expenses. Discount dental plans have a minimal annual fee whereby dentists in the “network” have agreed to discount standard fees for those on the plan. Indemnity and PPO plans generally have annual maximum benefits (standard is around $1000 per person per year). Most HMO plans do not have maximums but may limit services in other ways. Direct reimbursement is a fee-for-service, freedom of choice dental plan that is self-funded by the employer. Employees/patients pay for services and submit a receipt for reimbursement, which is based on dollars spent on dental treatment. According to the National Association of Dental Plans, in 2008 an estimated 3 million Coloradans were enrolled in a private dental plan and most (74%) were in a dental PPO plan (2.2 million).[129]
There are some unique challenges surrounding the private dental insurance market. From 2000 to 2006, family health insurance premiums for Colorado’s workers rose 5.5 times more quickly than median earnings. [130] On average, family health care premiums rose by 82%, while median earnings rose by only 15%.[131] Colorado has the ninth highest insurance premium rates in the United States. [132] From 2000 to 2005, the proportion of Americans covered by employment-based insurance dropped by nearly 5 percentage points (from 64.1% of adult Americans in 2000 to 59.5% in 2005). [133] With these trends, medical care costs are consuming ever-larger portions of family budgets and leaving fewer dollars for healthcare premiums and expenses often perceived as discretionary, like dentistry.
Out of-pocket is the final option to pay for dental services. In total, almost half of Colorado's population has no dental benefit and self-pays for dental services.[134] There are dental financing companies available that offer payment plans with interest for patients who need to pay over time. Dental school clinics and dental hygiene schools use students supervised by licensed faculty to provide services, which are generally 20-60% less than at a private dental office. However, there can be waiting lists for care, longer than average appointment times, and geographical challenges as, at present, there is only one dental school in Colorado, which provides care in two Denver area locations – at the University of Colorado Fitzsimmons Health Sciences Center in Aurora and the Children’s Hospital in Denver for pediatric patients. Dentists may also offer fee reductions for payment in advance or offer their own payment plan within the office. For those who truly cannot afford care, there are also several low cost and free dental clinics in Colorado.
Government Programs:
In Colorado, government programs provide most of the funding needed to make basic oral health care available to low-income children and pregnant women through the Medicaid and CHP+ programs. The total number of Medicaid clients in Colorado has nearly doubled over the past decade, to 500,000 people – or about 10% of Coloradans – in 2009. [135] As of December 2009, the CHP+ program covered 70,000 children and pregnant women. [136] The state department of Healthcare Policy and Financing (HCPF) oversees both the Medicaid and CHP+ programs. The total HCPF budget request for fiscal year 2009-10 was over $4 billion or approximately 21.1% of the state’s total budget, [137] and is made up of 39.5% state general funds, 49.1% percent federal funds, and 10.7% percent cash funds. [138] The Colorado Medicaid program currently receives $1.60 in federal funds for every $1 in state funds invested, up from a $1 to $1 federal-state match in 2005-2008.[139]
As evidenced in the recent growth in Colorado’s Medicaid program, enrollment in government plans tends to increase during times of economic down turns due primarily to higher unemployment. State budgets are stretched to provide necessary services. Hence, many strategies are employed to reduce the financial burden to the state, and yet attempt to meet federal requirements for matching funds. Further, appropriate federal funding must accompany federal mandates.
Until recently, the state’s Oral Health Unit in the department of Public Health and Environment provided about $500,000 per year to provide care for the most vulnerable senior and disabled populations through the state’s Old Age Pension Fund and a partnership with the National Foundation of Dentistry for the Handicapped. However, in recent budget cycles, the funding for these programs has been severely impacted. The Dental Assistance Program for Seniors through the Old Age Pension Fund typically served about 800 seniors annually, which is about 3 percent of the eligible Old Age Pension population. [140] To qualify for the Old Age Pension dental program, seniors must be 60 years of age of older, live in Colorado, and meet the income requirements to receive Old Age Pension public assistance. [141] The National Foundation of Dentistry for the Handicapped’s Donated Dental Service program also serves about 800 patients annually. [142] The program serves patients of all ages who cannot travel to a dentist’s office. Most patients are elderly. Continued collaboration between public and private health delivery systems should be a high priority to obtain maximum efficiency in delivery of services.
Colorado Department of Public Health also underwrites several school-based dental services such as sealants and fluoride varnish, as well as some provider incentive programs such as loan forgiveness programs and the Colorado Health Service Corps. Some Federally Qualified Health Centers (FQHCs) also provide dental care.
Safety Net:
Access to a dental care safety net for certain populations in Colorado is fragile. Dental care for the indigent, the working poor, developmentally and mentally disabled, and the elderly can be challenging to obtain. Even though Colorado's Medicaid and CHP+ programs have helped some children receive care, a large number of children are still experiencing difficulty in accessing care. Safety-net dental care for some adult populations is an even larger problem in Colorado. With the exception of emergency care extractions of teeth, there are no Medicaid benefits for adults in Colorado, including the elderly in nursing homes. Therefore, Colorado's safety net for care is critical for these populations.
Colorado's limited safety net is vastly smaller than in previous years. Government funded programs have continued to experience extensive budget cuts, especially in the past few years. In FY2009-10, the Colorado Department of Public Health and Environment’s Oral Health Unit (which oversees many prevention, education, and treatment services), was hit with almost $400,000 in funding cuts.[143] State grant funding to the school sealant programs has had ongoing reductions for the past several years.
Federally qualified health centers (FQHC) and community health centers (CHC) care for some of the nation’s most vulnerable populations. They are nonprofit or public health clinics that focus on providing primary healthcare services, including dental care, to Colorado’s low income residents. Health centers serve a large number of low-income Coloradans. In Colorado, CHCs have been providing services more than 45 years and assist approximately 450,000 patients each year. [144] 15 FQHCs (or CHCs) operate 123 clinic sites in 33 Colorado counties. [145] Of the fifteen CHCs, thirteen operate 39 dental clinic sites in 20 Colorado counties and provided over 190,000 visits to more than 78,000 patients in 2009. [146]
The University of Colorado School of Dental Medicine has a clinical program administered by faculty for the education and training of dental students and residents. The clinic provides an option for reduced-cost restorative services for underserved populations in the Denver/Aurora area and for those patients willing and able to travel. Treatment is provided by dental students under the direct supervision of dentists who are faculty members of the School of Dental Medicine. Most dental services that are available in private practices are also available at the school. The fees at the school are heavily discounted in exchange for the additional amount of time necessary for students to provide treatment and the patient's scheduling flexibility, but patients are expected to pay for services at each visit. The Children’s Hospital Healthy Smiles Pediatric Residency Dental Clinic also has a large and innovative pediatric dental clinic for children who have limited access to dental care. The clinic sees more than 25,000 children per year at reduced cost. The clinic is open for walk-in dental emergency care weekdays from 8-10 a.m. The clinic also offers general anesthesia for children who may benefit from sedation. The 3 Colorado dental hygiene schools also provide educational, preventive and hygiene services to patients in the school clinic setting on a discounted-fee basis, but do not provide restorative care.
CDA member dentists also give of their time and expertise to help those in need to obtain care. It is estimated that $10-15 million of donated dental care is given away each year in Colorado in pro bono dental care through various programs and in-office treatment. A recent survey of Colorado’s urban dentists reported that over 90% of Colorado dentists provided charity care in 2008.[147] While donated care is helpful in providing dental care to the less fortunate, it does not constitute a health care system. CDA dentists also support numerous other clinics financially such as Kids In Need of Dentistry, Howard Dental Center, and Inner City Health Clinics, to name a few.
Innovative Outreach:
Colorado dentists have always been leaders in seeking innovative ways to provide care to disadvantaged patients. A few of the many innovative dental outreach programs organized and supported by Colorado dentists are mentioned below.
Colorado Mission of Mercy (COMOM)
COMOM is a 100-chair portable dental clinic started in 2007 that travels to different areas of the state each year. Dental volunteers from across Colorado donate their time two days of free dental treatment to adults and children. In just four years, COMOM events have treated over 5,000 patients and provided over $3.5 million in donated care.
MDDF Smile Again
The Smile Again Program offers cost-free dental care to disadvantaged survivors of domestic violence. Organized by the Metropolitan Denver Dental Foundation, dentists in the community volunteer their time to provide free care to men, women and children who have survived situations of abuse or neglect.
Give Kids A Smile (GKAS) Give Kids a Smile is a day of free dental treatment and education for kids organized by the Colorado Dental Association. This program takes place on the first Friday of February each year. The next event will be held on Friday, February 4, 2011. Dental volunteers from across Colorado donate their time to help children without dental insurance or the ability to afford dental care. Children must have an appointment in advance to receive free care. On average, about 250 CDA member dentists volunteer to provide free preventive and restorative care to in-need children. In 2010, 375 volunteers cared for over 6,000 children in more almost 50 Colorado cities and provided dental services valued at over $750,000.[148] Over $3.2 million dollars in care has been provided since the program’s inception in 2004. [149]
Howard Dental Center
The Howard Dental Center provides comprehensive oral health care to adults, youth and children living with HIV/AIDS. For patients who are HIV+, regular oral health appointments can make a huge difference in their overall health. On an annual basis, the clinic performs close to 6,000 dental procedures and treats 450 patients.
Kids In Need of Dentistry (KIND)
Kids In Need of Dentistry (KIND) offers dental care, including reduced-cost orthodontic treatment, on a sliding fee scale based on income. KIND also has a mobile dental unit that travels throughout the state to provide care.
National Foundation of Dentistry for the Handicapped (NFDH) NFDH, through its affiliate the Colorado Foundation of Dentistry for the Handicapped and the Donated Dental Services program, arranges comprehensive dental treatment and long-term preventive services to needy disabled, elderly or medically compromised individuals through volunteer dentists in Colorado. They also offer a Dental HouseCalls program that provides in-home care to low income seniors who are too frail or ill to travel to a dental office. In 2009, Colorado dentists provided over $1.5 million in donated care through the program to over 450 Colorado patients.
Project Homeless
CDA was a 2010 sponsor of Project Homeless Connect, a one-day event that works to connect homeless individuals to needed services, including basic healthcare, legal services, IDs, birth certificates, food-stamp benefits, and information about employment opportunities and shelter openings. Metro area dentists provided free dental care during the May 22, 2010 event at Coors Field.
Rocky Mountain Youth Mobile Van
The mobile dental unit travels around the Denver metro area and to rural areas of Colorado. It provides dental care to uninsured children and adolescents.
Total Oral Prevention Strategies (TOPS)
TOPS is a non-profit, bilingual dental clinic serving Denver’s low-income preschool children and their families. TOPS provides free preventative care including dental screenings, cleanings, fluoride varnish applications and dental care education to parents. TOPS strives for early intervention that results in long term cost savings.
Women’s Resource Center
The Women’s Resource Center provides the opportunity for disadvantaged women in Larimer County to obtain affordable oral healthcare and dentures. In 2009, the dental program served 310 women, and 21 low-income adults received free dentures.
External Influences:
Access to dental care is being influenced by many factors that are outside the dental delivery system. Yet, external entities are gathering stakeholders and others to reorganize the dental delivery system. Entities, such as the Institute of Medicine (IOM), the Health Resources and Services Administration (HRSA), numerous foundations and policy institutes are initiating oral health policy and advocacy discussions without involving organized dentistry as part of their planning and implementation. The current economic climate is also playing a role in these discussions since financing care is a large part of the ongoing discussion on access to dental care.
Dentistry is a small part of health care spending and the impacts of newly enacted federal health care reform legislation is still unclear, especially in regard to what it will do to provide more care for children. It appears that it may actually offer less care in an effort to contain costs.
Large corporate and retail dental clinics have sought to bring innovations to the dental delivery system through economies of scale, multiple locations and expanded hours. In the future, traditional private practitioners in dentistry may explore some of these modalities as ways to offer the patient a more flexible dental delivery system.
Over the past several years more foundations have been trumpeting the message that organized dentistry has been proclaiming for decades: oral health care is important, especially for children. Colorado dentists are pleased that many organizations are recognizing the need for individuals and families to find a ‘dental home’ and that oral health affects overall health. Our concern is not with the increased interest in oral health, but with the approaches that many foundations are taking in affecting change in public policy.
Rather than focusing on the issue of underfunding of government based programs or focusing on programs to boost the dental IQ of the populace, some foundations are proposing programs to dismantle the current dental delivery model and promoting the individuals whose training is not equivalent to a dentist (MLPs) to provide diagnostic and restorative dental services. The use of MLPs is not a solution. It is another problem and one that can compromise the health and safety of the patient.
The CDA has grave concerns about the vast reach and implications of numerous organizations and foundations that are making decisions on dental care delivery and access to care based on faulty assumptions, inadequate data, and comparisons to the medical model. The profession believes that the health and safety of the patient is paramount. We believe that some of the proposed solutions being put forward by outside entities, in the name of access, do not place the health and safety of the patient first.
CONCLUSION
The Colorado Dental Association is dentistry’s voice in our state and seeks to work with any and all groups willing to help promote and provide access to quality dental care for Coloradans. We invite interested individuals to help the profession strive to find solutions to well-documented problems that we know can be addressed by better funding, implementing oral health literacy programs, establishing more safety-net programs for those who fall through the cracks and simplifying third-party insurance plans, which allow dentists to be more productive. Time and valuable resources should not be wasted in pursuit of proposals that lower the standard of care by creating a two-tiered delivery system and utilize models that have been proven not to work. Working together we can improve the oral health of all Coloradans.
-----------------------
[1] Academy of General Dentistry. White Paper on Increasing Access to and Utilization of Oral Health Care Services. July 2008.
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[3] CHI Oral Health Workforce Report, 2009. p. 4.
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