Position on Access to Care and Emerging Workforce Models

BACKGROUND STATEMENT

The National Dental Association, Inc. (NDA) views access as a matter of social justice. The NDA ascribes to the philosophy that health care is a right for all, not a privilege for a few. Despite advances in health care and technology, glaring disparities exist among underserved and vulnerable, diverse populations. In 2000, the widely quoted U.S. Surgeon General’s Report stated, “Although major improvements have been seen nationally for most Americans, disparities exist in some population groups as classified by age, sex, income, race/ethnicity.” (1)

In advancing the principle of health equity for all, the NDA has become the voice of moral authority for all of the underserved populations and has been concerned about access to Oral Health Care since the NDA’s inception in 1913. Sixty-two percent of NDA members are Medicaid providers, more than three times the amount in any other group in organized dentistry. The NDA promotes access for all to oral health care by serving the underserved and vulnerable populations. As both caregivers and citizens of the communities that we serve, the NDA’s members seek to improve the health of the underserved, eliminate disparities and promote health equity. NDA members are trusted and respected providers who have been at the forefront of treating those who have the least and need the most, creating dental homes needed to meet their needs. The NDA, by far, is shouldering an unequal burden of providing access to care for the underserved; and, as a result, is best qualified to speak on best options to achieve health equity and access. The NDA’s community practitioners are essential safety net providers who have made a commitment to community “first”, and who have for decades sacrificed personal and financial gains in order to bridge the gap in health disparities.

The goal is to craft and adopt a multi-faceted approach to a decades old problem that has not and will not be remediated by traditional methods. Consistent with recommendations of the Institute of Medicine and the National Research Council of the National Academies, this position statement is based on two widely accepted, evidence-based principles: (2)

  •   That oral health is an integral component of overall health and must, therefore, be a core component of comprehensive health care.
  •  That improving access to oral health care will prevent disease and improve overall health.

    Although some gains have been made in access to oral healthcare for all, they are not nearly enough. Consider the following:

  •   Only 34% of uninsured Americans had a dental visit in the past year. (3)
  •   More than 100 million American adults and children do not have dental insurance. (4)
  •   In 2011, 14.5 million Medicaid enrolled children didn’t get dental care. (4)
  •   In 22 states, Pew reports that fewer than half of Medicaid enrolled children received

    dental care. (4)

  •   In 2010, 2.1 million dental related ER visits had cost estimates up to $2.1 Billion. (5)
  •   Every state reports a decrease in adult dental benefits with increases in ER visits in the 21-35 age group. (6)
  •   There are currently 4,800 Dental Health Professional Shortage Areas based on a dentist to population ration of 1:5,000. (7)
  •   7,100 additional dentists would be required in order to meet the needs of the underserved in the dental shortage areas. (7)

    NDA REPORT FINDINGS

    Data from a NDA 2013 survey of NDA members indicated the need to more fully explore current oral health workforce issues. (8) Survey results revealed that 62% of NDA members are Medicaid providers; and that 76% of respondents did not believe that they had been adequately informed about the Emerging Workforce Models. In addition, 77% stated that they were not aware that the NDA had abandoned the use of the term “Mid-level provider” in favor of “Emerging Workforce Models (EWM)”. When asked if their “state adopted credentialing for EWM providers (expanded function dental hygienists, expanded function dental assistants, or dental therapists), would you add them to your staff to increase productivity?”, 60% (59.9%) responded “yes”. When asked if their “state allowed, and reimbursed for, distributed telehealth connected dental teams”, 90% said they would be interested in “finding out more about how this might work”.

    When asked “If you could profit financially from hiring an EWM, AND increase access to care, would you consider it?”, 75% (74.7%) responded “yes”. (8)

    Research has proven that better health outcomes are achieved when ethnic minority populations are served by ethnic minority providers. (9) That is why the NDA members are committed to increasing the number of African American dentists and other oral health care professionals in the workforce in our communities. The views of the IOM are shared by the NDA, specifically stating that, “ensuring that non-dental health care professionals are properly trained to take a role in delivering quality oral health care will be crucial. The core set of oral health and cultural competencies developed for non-dental professionals need to be developed with input from a variety of stakeholders to ensure that the competencies are appropriately broad and therefore, applicable to many health professionals. The competencies also need to reflect the collective expertise and experience of dental professionals and their non-dental counterparts to ensure that the competencies prepare professionals to provide care that meets appropriate standards of quality (i.e. care that is safe, timely, effective, efficient, equitable, and patient-centered.)”(10) With all things considered, the Position Statement is delivered in the context of recommendations pursuant to Patient Issues and recommendations relevant to Provider Issues, specifically in vulnerable and underserved communities.

PATIENT ACCESS ISSUES
Recommendation 1: Increase underrepresented minorities in the oral health careers. Recommendation 2: Consider workforce development as a determinant of access.

  1. The NDA supports the development and continuation of demonstration projects that can demonstrate the impact and effectiveness of Emerging Workforce Models on access to care, and total health outcomes. Support the full utilization of existing oral health providers. Safety net dental providers should play leadership roles in community-based training, oversight, and advisory capacities.
  2. The NDA supports quality education and training; curriculum; scope of service; appropriate supervision; cultural competency; and safety net providers in vulnerable communities serving as adjunct faculty and community-based clinical preceptors.
  3. Dental Boards, as regulatory and credentialing bodies, should reflect the cultural, ethnic and gender composition of the population in the states being served.

Recommendation 3: Prioritize prevention and total health.

  1. Develop and deliver targeted messages for Community Health Education.
  2. Mandate workforce cultural and linguistic competency.
  3. Promote inter-active, inter-professional collaboration for patient-centered care.

Recommendation 4: Influence public policy reform and impact public policy outcomes.

The NDA recommends adopting a core set of national standards for consistent, high-quality education for all Emerging Workforce Models, including the Dental Therapist; and that these standards should be consistent with the Advisory Panel Report and Recommendations of Community Catalyst (11), as well as those outlined by the American Association of Public Health Dentistry. (12) The scope of practice, supervision, and workforce regulations should be based on competence, education, training and safety of the services.

Recommendation 5: Promote research and data collection.

  1. The Centers for Medicare and Medicaid Services (CMS) should fund and evaluate state- based, Community-Based Participatory Research (CBPR) demonstration projects that cover essential oral health benefits for Medicaid beneficiaries, children and adults.
  2. HRSA should support projects established in FQHCs.
  3. Office of Minority Health, NIDCR and Minority Health Institute should support demonstration projects and should be extended to include private practitioners who practice in underserved, diverse population areas.

Recommendation 6: HRSA should dedicate Title VII funding to NDA practitioners serving as community-based preceptors for expanded and interprofessional teams.

PROVIDER ISSUES IN UNDERSERVED COMMUNITIES
Recommendation 1: Provide incentives, guidelines and protection for Medicaid providers, public and private.

  1. Reduce financial and administrative barriers
  2. Medicaid providers are safety-net providers and should be considered “Essential Providers”.
  3. States should promote and reward maximizing access to care and optimal utilization of Medicaid programs.

Recommendation 2: HRSA should Increase Title VII funding for recruitment to support the advanced dental education of URM and lower-income applicants and those from rural areas.

Recommendation 3: Provide community/state based incentives for providers to establish businesses in Dental Health Shortage Areas. (Loan repayment, low interest loans, tax credits for accepting reduced Medicaid fees, business and finance programs, etc.).

  1. Provide training for dentists as leaders of expanded oral health teams and inter- professional teams.
  2. Create programs for dentists and students to learn about alternative practice delivery systems in preparation for future business trends, technological advances and consumer demands.

Recommendation 4: Standardize protocols and processes for Medicaid auditing, re-credentialing, and providers’ appeal mechanisms. Ensure that providers are fully aware of and knowledgeable of the process.

Recommendation 5: Cultivate collaborations with community health centers, FQHC’s, and non- dental safety net health providers to increase referrals and encourage enrollment, optimize access and increase utilization of public assistance programs.

Recommendation 6: State laws should allow allied dental personnel to work in a variety of settings under evidence-supported supervision levels; and practice to the full extent of their education and training to allow dentists to more productively use their training and skills to treat patients with complex needs.

Recommendation 7: Scope of practice, supervision, and workforce regulations should be based on competence, education, training and safety of the services to ensure that there are no double- standards of care in our most vulnerable, underserved and diverse populations.

REFERENCES

  1. “Oral Health in America: A Report of the Surgeon General”, USDHHS, USPHS, 2000. P. 35
  2. Institute of Medicine and National Research Council, “Improving Access to Oral Health Care for Vulnerable and Underserved Populations”, National Academy of Sciences, 2011
  3. http://www.deltadental.com/AmericaOralHealthRole DentalBenefits.pdf, P.4
  4. “In Search of Dental Care” Issue Brief, Pew, June 2013
  5. NHAMCS-National Hospital Ambulatory Medical Care Survey; Tanner, L. USA Today Feb. 2012
  6. American Dental Association Health Policy Research Brief, 2013
  7. http://www.hrsa.gov/shortage, Jan. 2014
  8. NDA Workforce Survey Results, 2013
  9. Zayas, L., McGuigan, D., “Experiences Promoting Healthcare Career Interest Among High School Students from Underserved Communities”, J National Medical Assoc, Sept. 2006
  10. Institute of Medicine and National Research Council, “Improving Access to Oral Health Care for Vulnerable and Underserved Populations”, National Academy of Sciences, 2011
  11. “Recommended Standards for Dental Therapy Education Programs in the US”, Advisory Panel Report and Recommendations, Community Catalyst, Oct. 2013
  12. Evans, C., “The Principles, Competencies, and Curriculum for Educating Dental Therapists: A Report of the American Association of Public Health Dentistry Panel”, JPHD, Vol. 71, 2011

    BIBLIOGRAPHY

1. Kellogg News Release, “First U.S. Private Practice to Employ Midlevel Dental Provider sees Increase in Profits and Ability to Treat Medicaid Patients”, Feb. 12, 2014

  1. Journal of the American Association of Public Health Dentistry, Vol. 71 Special Issue: Workforce Development in Dentistry: Addressing Access to Care, Spring, 2011
  2. Oral Health Care Workforce-Current and Proposed Providers, American Dental Hygienists Association, 2010
  3. Community Catalyst Recommended Standards for Dental Therapy Education Programs in the United States, October 2013
  4. Fletcher, N., “Executive Summary Oral Health and Health Care Reform: Challenges and Opportunities for Workforce Expansion”, April 15, 2011
  5. 2012 National Healthcare Disparities Report, Agency for Healthcare Research and Quality, May 2013
  6. Alston, PA, Knapp, J., Luomanen, JC, ”Who Will Tend the Dental Safety Net?”, JCDA, Feb. 2014
  7. Creating Standards for Consistent, High-Quality Dental Therapy Education in the United States, Community Catalyst, Oct. 2013
  8. “Core competencies for Interprofessional Collaborative Practice, Report of an Expert Panel, AAMC, ADEA, AACN, AAQCOM, ASPH, AACP, May 2011
  9. State of Children’s Dental Health: Making Coverage Matter, PEW Center on the States, May 2011

Adopted by the National Dental Association House of Delegates, July 27, 2014