FDA Access to Care

IMPROVING ACCESS TO ORAL HEALTH CARE

IN FLORIDA

Provided by the members of the Florida Dental Association

THIS WHITE PAPER EXPLAINS THE BARRIERS TO ACCESSING DENTAL CARE IN FLORIDA, WHAT IS CURRENTLY BEING DONE TO ADDRESS THE PROBLEM, AND WHAT SOLUTIONS EXIST THAT, IF IMPLEMENTED IN TOTALITY, COULD IMPROVE THE ORAL HEALTH OF MILLIONS FLORIDIANS.

2DENTISTRY: GATEWAY TO GOOD HEALTH FLORIDA DENTAL ASSOCIATION

IMPROVING ACCESS TO ORAL HEALTH CARE

IN FLORIDA

EXECUTIVE SUMMARYIt is the position of the Florida Dental Association that every Floridian should understand that good oral health is important to overall health and well-being. Good oral health does not just happen; it is the result of both personal responsibility and professional care. The great majority of Floridians (more than 70 percent) receive high quality dental care. Unfortunately, that is not where the story of Florida’s oral health ends. For the other approximate 30 percent of Floridians, the system is broken. Only 23.5 percent of Medicaid enrolled children and 11 percent of Medicaid adults receive any dental care annually. This White Paper explains the barriers to accessing dental care in Florida, what is currently being done to address the problem, and what solutions exist that, if implemented in totality, could improve the oral health of millions Floridians.

Lack of access to care is the result of many factors, including patients’ perceived need for care, lack of oral health literacy, geographic distribution of dentists and dental teams, financial support for care and transportation challenges to name a few. It is important that government, dental professionals, and advocates work together to identify and address the many barriers to access to care.

CONTENTS (CLICK TO LINK TO PAGE)Executive Summary 2Introduction 4Prevention 5Improve Oral Health Literacy 5Improve the Safety Net: Government Programs 6Expanding the Opportunities within the Current Dental Workforce 7Improve Advocacy & Collaboration 8Expand Volunteerism and Innovative Outreach 8Conclusion 8Recommendations 9Works Cited 11Acknowledgments 12


Currently, dentists across the state are making attempts to address the problem through volunteerism. The FDA foundation sponsored Project: Dentists Care – which is a dental access to care program that brings dentists and dental teams together as volunteers to provide dental care to those in greatest need – provided more than $10 million worth of dental services to underserved residents in Florida in 2010. The amount is equal to about 10 percent of Florida’s dental Medicaid budget for 2010. But, these efforts are simply not enough to address the systemic and ever growing gap in access to care in Florida.

The government has the responsibility of addressing the access to care gap; but its efforts have been inadequate. Dental Medicaid represents a very small percentage of the annual state Medicaid budget. In 2010, Florida’s entire Medicaid budget was $20.2 billion and the amount spent on dentistry in that same year was $117 million, making dentistry only 0.6 percent of the state Medicaid budget.

The FDA believes that focusing on six areas will help increase access to oral health care so that all Floridians may enjoy good oral health.

1. Prevention: For every dollar spent on prevention there is a four-dollar savings in treatment costs. Although preventative measures such as fluoridated water, sealants, and dental health education are used in Florida, the increase in such treatment would greatly reduce the access to care gap. Evidence shows that fluoridated public water systems reduce the rate of cavities in high-risk children by an estimated 40 percent and by an estimated 12 percent in that of the general population. Sealing the biting surfaces of first permanent molars through sealants has also been shown to reduce rates of cavities by more than 50 percent over a 4.5-year period and 35 percent after 9 years. Expanding preventative care to both a greater geographic and economic population is the first step in increasing access to care in Florida.

2. Improve oral health literacy/education to those in need: Traditional approaches of teaching have been shown to improve knowledge about oral health; unfortunately there is no clear evidence that such approaches produce the desired outcome of improved oral health through modified health behaviors. The average American reads at an eighth or ninth grade level. However, most health information is written at a higher reading level. It has been estimated that individuals with diminished or limited health literacy cost the U.S. between $100 and $200 billion each year (Vernon, et al. 2007). New methods of educating sensitive populations and those who care for them,

including seniors, nursing home employees, children and their parents, and both public and private schools must be developed and deployed. Some methods include promoting good dietary habits by removing soft drinks from schools, educating the public on the consequences of non-fluoridated bottle water, and educating parents on proper home dental care.

3. Improve the oral safety net: Encourage the proper funding and utilization of existing programs such as Medicaid and Florida Healthy Kids. The Department of Health (DOH) should employ a full time Florida licensed public health dentist who is knowledgeable in the unique aspects of dental health as its director. This individual is necessary to properly direct limited resources in an efficient manner to meet the needs of all of Florida’s vulnerable citizens.

4. Expand opportunities within the current dental workforce: We should encourage the use of expanded functions dental auxiliaries and dental hygienists to increase the availability of dental care in health access settings. The government should adequately fund existing dentists’ positions in county health departments and add positions in areas of need. Either the state or federal government must also step up and use dental student loan forgiveness and other incentives to encourage dentists to establish private practices in dental shortage areas.

5. Improve advocacy and collaboration: All oral health stakeholders must communicate with one another. The American Dental Association (ADA) Council on Access, Prevention & Interprofessional Relations sums it up best, “To collaborate with internal and external stakeholders to create advocacy strategies regarding access to care, population-based prevention and interprofessional relations.” The FDA is committed to working together with interested parties to reduce barriers to care.

6. Increase volunteerism and innovative outreach: While current volunteerism efforts have been, and continue to be, invaluable to tens of thousands patients in Florida, more innovative approaches will continue to be a mission of the FDA.

The FDA recognizes that not all Floridians enjoy or desire the same level of access to oral health and hopes that the information within this paper will make all parties more aware of the issues that underlie the inequalities of oral health care. If the state and federal government can work in concert with the dental community and make financially honest commitments, together we can end the needless suffering caused by dental disease in Florida.

Project: Dentists Care provided more than $10 million wor th of dental services to underserved residents in Florida in 2010.


INTRODUCTIONAccording to the 2000 Surgeon General’s Report, dental caries (cavities) is identified as the most common chronic disease of childhood, five times more common than asthma.6 Dental caries (cavities), both untreated and treated, have a major impact on all Floridians especially the young and elderly. The oral health of Floridians does not meet the standards set in Healthy People 2010 or the more recent Healthy People 2020 objectives set forth by the U.S. Department of Health and Human Services. One’s understandings of the need for good oral health along with the ability to access dental care are key elements in achieving a healthy population. Evidence demonstrates that low income patients perceive good oral health as the lack of pain.4 Unfortunately not all Floridians understand the importance of regular preventive dental care. Many disadvantaged individuals seeking dental care have difficulty finding a dentist because of policies (both financial and administrative) that discourage dentists from participating in Medicaid, SCHIP (KidCare), and other government subsidized dental programs . In Florida these programs are inadequately funded and oftentimes do not cover the dentist’s costs of providing the services. Government and the public must be made to understand that the majority of dental disease can be prevented by good oral hygiene, water fluoridation, regular dental visits and basic healthy dietary behavior. For every dollar spent on prevention there is a four dollar savings in treatment costs.5

Florida has failed to submit key data needed to assess the state of Floridian’s oral health to the United States Centers for Disease Control (CDC). This includes data on sealants placed on permanent teeth, caries experience and untreated tooth decay. Planning and executing an organized assault on dental disease in Florida necessitates having this critical data in hand. It is incumbent on the appropriate State agencies to collect this need information. Only 23.5 percent of Medicaid-enrolled children, age 18 and under received any sort of dental care in 2008, the most recent year for which federal data were available. In Idaho, the top-ranked state, 61 percent of eligible Medicaid children saw a dentist during the past year.7 According to Florida Head Start, low income children are affected more than affluent children. Hispanic children are affected more than non-Hispanic children, and Black children are affected more than White children. In Miami-Dade County, 60 percent of poor minority children 5 years of age and under have untreated dental caries.

The lack of access to dental care has become a much used political buzz word. But, what is access to oral health care? Thus far, none of the interested parties has either put forth or agreed on a definition of “access to dental care” and more importantly “adequate” access to dental care. As a result, the solutions to better access presented by individual groups will be quite different. What we need to ask is how many of the underserved population were able to progress with the aid and treatment from dental professionals to a state of good oral health in the past year?

Lack of access to dental care is the result of a multitude of inadequateness demonstrated by all parties’ involved - dental professionals, government officials as well as those individuals with unresolved dental needs. The problem is further complicated by many social and economic issues. The sheer number and complexity of factors make the collection of barriers to the access to dental care unique to each individual. According to the Academy of General Dentistry, solving the access problem requires that those interested in helping a person get access to 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”.10 Unfortunately, based on the complexity and individual uniqueness of the issues, there is no single good solution for solving the access to oral health problem in Florida.

Barriers to oral health care are not limited to just the poor; many working Floridians do not have dental insurance and must pay for dental care with discretionary dollars. Furthermore, the maximum benefit of employer dental benefit plans have not kept up with the cost of care leaving the policy holder responsible for the cost of the majority of their dental care. To further complicate the problem many dental plans fail to pay for preventive services.8

While workforce issues can be barriers, simply increasing numbers of providers will not by itself positively affect overall access to care. If all new graduates or “new providers” locate to areas that have traditionally attracted new dentists, nothing will change. There must be incentives and programs available to bring new dentists to those areas that are currently underserved. Maldistribution of dentists is a much greater issue than the total number of providers. We must not focus solely on the workforce necessary to treat anticipated dental disease; the prevention of dental disease is far more effective and less expensive than treating dental disease.

It is imperative that government, the profession and advocates work together to first identify the most common factors limiting access to oral health care and then formulate solutions. The FDA recognizes six broad categories of “barriers” that must be reduced if we are to assure that all Floridians can enjoy good oral health.

1. Preventive 2. Improve Oral Health Literacy3. Improve the Safety Net4. Expand the Opportunities

within the Current Dental Workforce 5. Improve Advocacy and Collaboration 6. Expand Volunteerism and Innovative Outreach


PREVENTIONWater 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. In Florida 94 percent of Floridians are using public water systems and 76 percent are receiving optimally fluoridated water (approximately 13 million people).11 Evidence shows that sealing children’s first permanent molars can save money by delaying or avoiding invasive treatment and the destructive cycle of caries. In a time of limited funds for dental services, these results should be considered by payers when establishing more rational sealant reimbursement policies.3

Children who have their molar teeth covered by a sealant are less likely to have dental decay in their molar teeth than children without sealants. Sealants are coatings applied by the dentist or by another person in dental care on the grooves of mainly molar teeth. These coatings are intended to prevent the growth of bacteria that promote decay in grooves of molar teeth. A recent review shows that after 4.5 years the sealed permanent molar teeth of children age 5 to 10 had

over 50 percent reduction in decay on biting surfaces compared to teeth without sealants. One study, with longer follow-up, showed that after 9 years only 27 percent of sealed tooth surfaces were decayed compared to 77 percent of tooth surfaces without sealants.

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.12 Florida’s oral cancer rate is higher by both race and gender when compared to national averages. According to statistics from the National Cancer Institute (2008), males have a higher incidence of oral cancer than females and the incidence of oral cancer among males in Florida is higher than the incidence of oral cancer among males in the U.S. Florida men rank fifth and Hispanic males rank first among all states. The use of alcohol and tobacco is a contributing factor to oral cancer.13 Education and regular oral exams can detect early cancer and result in better outcomes.

IMPROVE ORAL HEALTH LITERACYOral 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”.14 Low oral health literacy can affect any population group and can have a significant impact on a person’s ability to understand instructions given by a dentist or hygienist, difficulty understanding instructions on prescription bottles and the importance of showing up for a dental appointment. Additionally, their limited understanding of oral health may hinder their ability to make appropriate health care decisions in a timely manner.

The average American reads at an eighth or ninth grade level. However, most health information is written at a higher reading level.15 Limited literacy skills are a stronger predictor of an individual’s health status than other common factors such as race, ethnicity, age, income or education level.16 It has been estimated that individuals with diminished or limited health literacy cost the U.S. between

$100 and $200 billion each year (Vernon, et al. 2007). Increasing oral health literacy to the extent that it will positively influence oral health behavior 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. Traditional approaches of teaching have been shown to improve knowledge about oral health; unfortunately, there is no clear evidence that such approaches produce the desired outcome of improved oral health through modified health behaviors. New methods of educating children and their parents must be developed and deployed. Parents should be educated to encourage breastfeeding, avoid unhealthy feeding practices, brush their child’s teeth until they have the manual dexterity to do so themselves (usually by the age of 6 or 7) and reinforce older children’s good tooth brushing habits.

Water fluoridation helps to reduce the caries rate in children and adults.


IMPROVE THE SAFETY NET: GOVERNMENT PROGRAMS

In Florida, government programs provide most of the funding for basic oral health care available to low-income children and pregnant women as well as for those with certain disabilities.

Government programs include Medicaid and SCHIP (KidCare) plans. Medicare does not pay for dental services, except for those that are an integral part of a covered medical procedure. Medicaid is available to people with limited incomes. In Florida, dental benefits are primarily available for individuals under age 21, with the exception of pregnant women and those whose family has an income of 100 – 200 percent of the federal poverty level (FPL) or less depending on the category the individual falls within. Medicaid covers most standard preventive and basic restorative services for children. However, Florida’s Medicaid program for adults is limited to emergency extractions, and full and partial dentures. An analysis commissioned by the Florida Public Health Institute and conducted by the Health Council of Southeast Florida found more than 115,000 hospital emergency room visits in 2010 for treatment of conditions considered avoidable with proper preventive and restorative dental care. Total charges exceeded $88 million. KidCare provides comprehensive health care, including dental benefits, to eligible children. Eligibility is granted if a family’s income is more than 200 percent of the FPL but less than or equal to 235 percent of the FPL. A sliding scale monthly premium is charged for children ages five to 19 based on family income. In Florida all KidCare dental coverage is through managed care providers.

In FY 2010, the Florida Medicaid program served 2.6 million clients with federal and state expenditures of $20.2 billion. The Florida Medicaid program receives $1.63 in federal funds for every $1 of state funds that it spent. Funding for KidCare is provided by the state of Florida, the federal government (Title XXI funds), and premiums collected for children ages six through 18. Federal funds are available to subsidize nearly 73 percent of the benefit cost, less premiums, with the remaining 27 percent coming from the state of Florida. The percentage of federal matching is adjusted annually.

Dental Medicaid represents a very small percentage of the annual state budget. In 2010, Florida’s Medicaid budget was $20.2 billion and the amount spent on dentistry in that same year was $117 million making dentistry only 0.6 percent of the state Medicaid budget.

Enrollment in government plans tends to increase during times of economic downturns generally due 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. Florida has sought to cap their risk by transferring the risk to private for-profit entities such as managed care organizations. Because managed care organizations are potential risk bearers, it is in their best interest to implement policies that minimize their risk and maximize profit. These prepaid plans tend to limit the number of participating dentists, reduce reimbursement to providers, and/or eliminate certain treatment codes. The result is that fewer providers can afford to participate in the government program and access for this patient population can be challenging.

ACHA has failed to provide data on its’ 7 year pilot program in Miami-Dade despite multiple request by the FDA. Florida’s DOH offers limited dental services through the county health departments and dental services are also provided at federally qualified health centers (FQHC). There are presently 113 full-time equivalent (FTE) dentists employed by FQHCs that treated approximately 186,000 patients. The average 1,645 patients per FTE dentist is slightly more than the 1,500 suggested by the federal government. It is disturbing given the great dental needs of this population that 62 percent of the procedures performed were an exam, prophylaxis or fluoride, while only 15.4 percent were restorative and just 2 percent were emergency visits. Unfortunately, in some areas of Florida these groups literally compete for the same patients as private practice Medicaid and KidCare providers which create yet another disincentive for dentists to participate. This disincentive is a result of the FGHC school programs ability to take away patients that where previously on private dentist capitation roles. Better collaboration between public and private health delivery systems should be a high priority to obtain maximum efficiency in delivery of services. Appropriate federal funding must accompany federal mandates.

Floridians over the age of 65 represented 17.2 percent of the population in the year 2009, but are expected to double by 2030. However, they will present greater health care demands, including demand for dental care. Presently less than 10 percent of the elderly have dental insurance. Efforts to improve dental care delivery must account for these new and greater demands.

“Medicaid and Public Health / A Broken System: The Institute of Medicine’s report, America’s Health Care Safety Net (2000)”, defines safety net providers as those who “organize and deliver a significant level of dental care and other dental health-related services to uninsured, Medicaid, and other vulnerable patients.” Safety net clinics may be operated by federally qualified health centers, local health departments, and neighborhood health centers that are private not-for-profit agencies, rural health centers, Indian Health Service or tribal units, institutions, schools, hospitals or other entities. Dental care for the indigent, the working poor, developmentally and mentally disabled, and the elderly can be challenging to obtain in Florida. Even though Florida’s Medicaid and KidCare (SCHIP) programs have helped facilitate children to receive care, many children are still experiencing difficulty in accessing needed care. Accessing safety-net dental care is a problem for a significant portion of our state’s adult population. With the exception of emergency care for extractions of teeth, and full and partial dentures, there are no Medicaid benefits for adults in Florida which includes the elderly in nursing homes. Lack of government sponsored dental insurance creates additional barriers for these populations to access routine oral health care.

State funding to the local health departments has had ongoing reductions for the past several years. The DOH operates 34 county dental clinics and 3 public health mobile vans. Most of Florida’s 67 counties have no public health dental services.


EXPANDING THE OPPORTUNITIES WITHIN THE CURRENT DENTAL WORKFORCE

An adequate workforce is a key element for 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.

Over the last several years the workforce for government funded programs decreased dramatically. The majority of this departure was due to dentists voluntarily leaving the Medicaid program after Medicaid reform transferred implementation of Medicaid dental services to managed care companies.

The process of designating dental health professional shortage areas (DHPSAs) has implications for access to care and proposed solutions to addressing access to care. Originally DHPSA designations were based on a goal of encouraging dentists to practice in remote locations, true shortage areas. Over time they have evolved into designations that are based on need, but the nomenclature has not been modified to reflect this change. Consequently, the nomenclature

is now illogical and implies that simple solutions (more dentists and/or expanded scopes of service) can solve a highly complex issue. The nomenclature does not address the intricate issues related to the demand for dental care (economics, oral health literacy, cultural barriers, transportation, etc.). The number of DHPSAs has increased dramatically and is now at the point that the designation may now exaggerate the need for additional dentists. The benefits associated with the DHPSA designation may no longer predictably target the areas having the greatest need. Presently, more than 2.9 million Floridians live in a dental health professional shortage area.18

There are distinct differences between the delivery of dental and medical treatment and therefore dental programs should not be bundled with medical Medicaid in the state budget. Dental care delivery and financing systems must emphasize prevention, the dental home concept and administrative efficiency. The FDA supports innovative ways of maximizing the abilities of the current workforce. It is the organization’s belief that the present workforce can serve many more Floridians as we explore opportunities to integrate certain duties and responsibilities of the current dental team. The FDA is open to all ethical solutions that do not endanger the public and at the same time increase access to dental care for all Floridians.


IMPROVE ADVOCACY & COLLABORATIONAccess to dental care is being influenced by factors that are extraneous to the dental delivery system. External forces are gathering stakeholders and others to reorganize the dental delivery system.

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; however, the newly enacted federal health care reform legislation appears to offer less care in an effort to contain costs. As dental providers, we know the most effective way to lower the cost of dental care is through prevention and encouraging the proper behaviors that will lower the costs to individuals and to government-funded programs. Ways to make the current system more efficient will also generate savings, but not without significant focus on prevention.

Over the past several years more and more foundations have begun trumpeting the message that organized dentistry has been proclaiming for decades: oral health care is important, especially for children and the elderly. Florida’s 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.

It is imperative that all oral health stakeholders communicate with one another. The American Dental Association Council on Access, Prevention & Interprofessional Relations sums it up best, “To collaborate with internal and external stakeholders to create advocacy strategies regarding access to care, population-based prevention and interprofessional relations” The FDA is committed to working together with interested parties to reduce barriers to care.

EXPAND VOLUNTEERISM AND INNOVATIVE OUTREACH

The FDA has always been a leader in seeking innovative ways to provide care to disadvantaged patients. A few of the many innovative dental outreach programs supported by Florida dentists are mentioned below.

The FDA’s charitable arm, the Florida Dental Health Foundation (FDHF), issued $75,000 in grants in 2010 for oral health care initiatives. The Foundation has also placed 52 affiliate PDC clinics around the state to provide free or reduced fee dental care.

PDC is a dental access to care program that brings dentists and dental hygienists together as volunteers to provide dental care to those

in greatest need. The PDC and its volunteer dental professionals provided more than $10 million worth of dental services to underserved residents in Florida in the 2010 year. That amount is equal to about 10 percent of Florida’s dental Medicaid budget for 2010.

PDC also hosts a series of events throughout the state during Give Kids a Smile (GKAS) month, which is held in February each year. GKAS is designed to provide education as well as preventive and restorative care to low-income children who do not have access to regular dental care. All GKAS volunteers provide free dental education, screening and treatment.

CONCLUSIONMuch emphasis has been placed on providing services needed to care for those who have already suffered the consequences of oral diseases; little has been done to influence Florida’s population practicing routine oral care to avoid these consequences. Our efforts and resources must be shifted from the present, late intervention, curative model to an early intervention, preventive oral health policy. Innovative approaches are needed before an appropriate, evidence-based, effective, cost-effective, sustainable and equitable -Model for oral health care can be implemented. This new approach to population oral health will require substantial commitment and

political will on the part of dental professionals, the public and government.19

The FDA is dentistry’s voice in our state and seeks to work with all groups willing to help promote and provide access to quality dental care for all Floridians. We invite interested individuals to help the dental profession strive to find solutions to the well documented problems that we know can be resolved through better funding, implementing oral health literacy programs and establishing more safety-net programs for those who are presently unnoticed and falling through the cracks of a broken system.


RECOMMENDATIONSThe following are additional recommendations to help gain adequate access to oral care and improve the general oral health of all Floridians.

PREVENTION:

1. Increase the proportion of eligible low-income elementary school children who receive sealants on the chewing surfaces of permanent teeth.

2. Increase the number of high-risk children receiving dental screenings and referrals to dentists for care.

3. Increase the number of high-risk expectant mothers that receive dental care and oral health instruction.

4. Increase the number of elderly and home bound that receive basic dental care.

5. Maintain the number of Floridians served by fluoridated community water systems with optimal levels of fluoride.

6. Advocate for more data collection and surveillance by the appropriate state agencies to determine the oral health status of Floridians, especially children, expectant mothers and the elderly.

7. Work with legislators to establish laws that mandate reporting of all dentally related emergency room visits and how those visits are funded.

8. Secure funds to establish a dental awareness campaign targeted to those who lack routine dental care (similar to the anti-smoking/tobacco campaigns).

ORAL HEALTH LITERACY AND BEHAVIOR:

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 Floridians on the importance of annual oral cancer screenings and educate Floridians on the dangers of tobacco use and sexual behaviors as they pertain 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. Advocate an oral health education component for public schools’ health curricula.

5. Form collaborations and partnerships with other interested groups to develop and disseminate oral health education materials.

6. Change perceptions of oral health as to why oral health is

important, as well as what simple steps individuals can take to preserve their personal oral health and that of their children and others under their care. Recognize possible signs of trouble and when to seek out care.

7. Engage community organizations in the development of health promotion and health literacy action plans focused on changing oral health behavior.

8. Establish an interdisciplinary collaboration of care among health care professionals to manage the overall health and oral health of Floridians.

ENCOURAGE UTILIZATION:

1. Initiate appropriate recruitment efforts to increase the numbers of under-represented minority and disadvantaged 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.

5. Encourage the enforcement of rules that require Medicaid and KidCare patients receive emergency care.

EXPAND CURRENT WORKFORCE:

1. Advocate for solutions for access to care, based on correct data and assumptions utilizing the experiences of all concerned parties.

2. Continue to monitor business trends that can positively impact the dental delivery system and educate dentists and government officials about opportunities to streamline and obtain economies of scale without compromising the quality of patient care.

3. Educate dentists in ways to maximize the use of the current workforce while maintaining dentist supervision.

4. Continue to advocate innovative ways to expand the capacity in current dental practices such as expanded functions auxiliaries.

5. Advocate and facilitate the discussion of all evidence-based solutions to access to care without personal or professional prejudice.

6. Advocate for more loan forgiveness programs and/or monetary incentives that give priority to providing treatment in underserved areas and to underserved populations.

SEE RECOMMENDATIONS, PAGE 10


RECOMMENDATIONS (CONTINUED)

7. Encourage the dental schools as well as the hygiene and dental assisting schools of Florida to evaluate how the curriculum, recruitment and financial options could best be structured to improve access needs to the underserved.

8. Advocate for grants and loan forgiveness supplementing the cost of dental education for those students willing to devote the bulk of their practice to treating the underserved.

9. Encourage Florida dental schools to structure GPR and AEGD programs to encourage and target dental school residents committed to working among specific populations of need.

IMPROVE THE SAFETY NET:

1. Advocate for government programs to eliminate wasteful middlemen (administrators) from Medicaid and SCHIP programs to assure that the maximum funds are used for dental care.

2. Advocate that government programs have goals and objectives that are relevant to population needs that are measured and re-evaluated in a timely manner.

3. Advocate for adult dental benefits under Medicaid and Medicare dental benefits for the elderly.

4. Encourage the DOH to re-establish county health department dental facilities to improve access to care for the low-income and aged, blind and disabled and to collect epidemical data for the assessment of their counties oral health.

5. Monitor the evolving health care reform legislation and advocate for appropriate dental benefits for the disadvantaged and underserved.

6. Advocate for government agencies which influence dental care such as DOH and AHCA to employ dentists in positions critical to the decision making process involving dental care for Floridians.

7. Initiate appropriate recruitment efforts to increase the numbers of under-represented minority and disadvantaged students in dental schools.

8. Encourage providers to increase their cultural competency to create trust and comfort, thereby influencing utilization of oral health care.

9. Work with the federal and state governments to provide additional financial incentives for dentists to provide regular care in underserved areas.

10. Advocate for a federal system to evaluate FQHCs based on the information maintained of individual patient needs and procedures provided and not by the number of encounters.

11. Monitor the use of FQHCs to prevent them from becoming solely Medicaid and KidCare providers - a trend that if continued will eliminate the safety net for the uninsured.

12. Continue to collaborate with stakeholders to maintain and to establish additional programs that are community-based solutions to access to care.

FINANCING DENTAL CARE:

1. Advocate that dental reimbursement fees for the Medicaid and KidCare dental programs be evaluated on a regular basis and that fees be established that are based on the actual cost of a service (labor and material) and not an estimate presented by a third party.

2. Adequately fund the Medicaid and KidCare programs through state and federal funding.

3. Offer incentives to dentists to establish practices in established areas of need, by providing state sales tax breaks for the purchase of equipment necessary to set up a dental practice and/or to build a practice.

4. Advocate for increased funding for public health dentistry that includes a plan on the most efficient use of the dollars.

5. 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 many Floridians.

6. Provide funding to expand dental clinics in all FQHCs and encourage competitive salaries for dentists and dental hygienists to attract providers.

INNOVATIVE OUTREACH:

1. Consider legislation that would provide state tax credits for donated dental services provided in volunteer clinics.

2. Lobby to change federal legislation which in effect prevents dentists that accept Medicaid from providing free services to other uninsured patients.

3. Lobby to change federal legislation that prevents community oral health programs that provide free dental care to the uninsured, to bill Medicaid for similar services provided to Medicaid patients.

4. Consider legislation that would extend sovereign immunity to dentists providing free services in their offices.


WORKS CITED1GAO. ORAL HEALTH Dental Disease Is a Chronic Problem Among Low-Income Populations GAO/HEHS-00-72. Washington: United States General Accounting Office, 2000. Report to Congressional Requesters.2Estimating the potential impact on dental caries in children of fluoridating a UK city. Downer MC, Drugan CS, Foster GR, Tickle M. 2011, Community Dent Health., pp. 34-9.3Assessing Cost-Effectiveness of Sealant Placement in Children. Quiñonez, R., et al., et al. 2005, Journal of Public Health Dentistry, pp. 82-9.4Perception of dental illness among persons receiving public assistance in Montreal. Bedos C, Brodeur JM, Levine A, Richard L, Boucheron L, Mereus W. 2005, Am J Public Health, pp. 1340-4.5Delta Dental. A Market Report on Dental Benefits: America’s Oral Health. s.l.: Delta Dental, 2007. Electronic www.deltadental.com/i_pdf.pdf.6U. S. Department of Health and Human Services. Healthy People 2010. Washington: U. S. Department of Health and Human Services, 2000.7Pew Center on the States. The State of Children’s Dental Health: Making Coverage Matter. Washington: The Pew Charitable Trusts, 2011.8The differences between dental and medical care . Guay, A. 2006, J Am Dent Assoc, pp. 801-806.9The impact of universal access to dental care on disparities in caries experience in children . Ismail, Amid and Sohn, Woosung. 2001, J Am Dent Assoc, pp. 295-303.10Dentistry, Academy of General. White paper on Increasing Access To And utilization Of Oral Health Care Services. 2008.11Florida Department of Health. Florida Department of Health Policy Statement on Fluoridation . Tallahassee: s.n., January 2008.12Rises LAG, Eisner MP, Kosary CL, Hanke BF, Miller BA, Cleg L,. SEER Cancer Statistics Review, 1975-2001. Bethesda: National Cance Insitute, 2004.

13Florida adults’ oral cancer knowledge and examination experiences. Tomar SL, Logan HL. 2005, J Public Health Dent., pp. 221-30.14Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville: National Institutes of Health, 2000.15American Dental Society. Health Literacy in Dentistry Action Plan. Chicago: American Dental Association, 2009.16Lynn Nielsen-Bohlman, Allison M. Panzer, David A. Kindig. Health Literacy A Prescription to End Confusion. Washington: The National Academies Press, 2004.17Dental self-care and visiting behavior in relation to social inequality in caries experience. Brennan, DS, Spencer, AJ and Roberts-Thomson, KF. 2011, Community Dent Health, pp. 216-21.18Florida: Health Professional Shortage Areas . [Online] September 30, 2008. [Cited: October 3, 2011.] http://www.statehealthfacts.org/profileind.jsp?cat=8&sub=156&rgn=11.19Dentistry and population approaches for preventing dental diseases. V, Baelum. 2011, Journal of Dentistry.20Medicaid Payment Levels to Dentists and Access to Dental Care Among Children and Adolescents. Decker, Sandra. 2011, Journal of the American Dental Association, pp. 1124-1125.21MEDICAID State and Federal Actions Have Been Taken to Improve Children’s Access to Dental Services, but More . Can Be Done, s.l.: Subcommittee on Domestic Policy, Committee on Oversight and Government Reform, House of Representatives, October 7, 2009.22Vernon, John, et al., et al. Low Health Literacy: Implications for National Health Policy. Washington: SCHOOL OF PUBLIC HEALTH AND HEALTH SERVICES, 2007.23NADP/DDPA. Decline in Dental Benefits Enrollment. Dallas: National Association of Dental Plans, 2010.

www.deltadental.com/i_pdf.pdf

www.deltadental.com/i_pdf.pdf

1111 E. Tennessee St.Tallahassee, FL 32308

800.877.9922 or 850.681.3629Web site: www.floridadental.orgEmail: [email protected]© 2012 Florida Dental Association

ACKNOWLEDGMENTSThe Florida Dental Association (FDA) “Improving Access to Oral Health in Florida” (White Paper) was developed by the FDA Board of Trustees’ Task Force on Access to Care in collaboration with task force consultants representing various dental organizations. The Florida Dental Association wishes to thank the following persons and organizations for their valuable input in the development of this paper, which represents an amalgamation of views but does not necessarily represent the policies or perspectives of any one organization. The White Paper could not have been completed successfully without the dedication, persistence, expertise and tireless efforts of these individuals, and therefore, they are recognized by name as follows:

TASK FORCE ON ACCESS TO CAREDr. Tom Ward, Chair, South Florida District Dental AssociationDr. Nolan W. Allen, West Coast District Dental AssociationDr. Jim Antoon, Central Florida District Dental AssociationDr. Phil Bilger, Atlantic Coast District Dental AssociationDr. Robert Payne, Northwest District Dental AssociationDr. Rick Stevenson, Northeast District Dental Association Dr. Cesar Sabates, ConsultantDr. Michael Chanatry, Florida Academy of PeriodontistsDr. Jimmy Glenos, Florida Association of OrthodontistsDr. Gerald Goebel, Florida Prosthodontic Association Dr. Gary Myers, Florida Academy of Pediatric DentistryDr. Tim Temple, Florida Association of EndodontistsDr. Donald Thomas, Florida Academy of General DentistryDr. Don Tillery, Florida Society of Oral & Maxillofacial Surgeons

FDA BOARD OF TRUSTEES 2011- 2012Dr. Cesar Sabates, President Dr. Kim Jernigan, President-elect Dr. Terry Buckenheimer, First Vice-president Dr. Rick Stevenson, Second Vice-president Dr. Ralph Attanasi, Secretary Dr. Larry W. Nissen, Immediate Past-president Dr. Paul BenjaminDr. Gerald BirdDr. David BodenDr. Steve Cochran Dr. Lee Cohen Dr. Don Ilkka Dr. Bryan (Tim) Marshall Dr. Jolene Paramore Dr. John Paul Dr. Tom Ward Dan Buker, Executive Director

STAFFRusty Payton, Chief Operating OfficerGraham Nicol, Chief Legal CouncilJoe Anne Hart, Director of Governmental Affairs

For additional information or documentation on the topics discussed in the White Paper, contact the Florida Dental Association’s Executive Office.

www.floridadental.org

mailto:gao%40floridadental.org?subject=

Documents

FDA Access to Care