“Position on Access to Care: Patients, Providers and Workforce” adopted October 6, 2016
The NDA views access to health care as a matter of social justice. We ascribe 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 populations. In 2000, the widely quoted 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 the underserved and has been concerned about access to oral health care since our inception in 1913. Sixty-two percent of NDA members are Medicaid providers2, more than three times the amount in any other group in organized dentistry. The NDA promotes access 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. They 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 is, by far, shouldering an unequal burden of providing access to care for the underserved; and is best qualified to speak on best options to achieve health equity and access. Our community practitioners are essential safety net providers, who have made a commitment to community “first”, and for decades have 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 National Academy of Medicine (formerly the Institute of Medicine (IOM) and the National Research Council of the National Academies), this position statement is based on two widely accepted, evidence-based principles: 3
- That oral health is an integral component of overall health and therefore, must 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 care, they are not nearly enough. Consider the following:
- Individuals who lacked dental insurance were about two-thirds less likely than people with private insurance to have had a dental visit within the last year (1 percent compared with 50.9 percent) 4
- As of September 2015, 22 states did not provide any dental benefits to adults in their Medicaid programs beyond emergency procedures.5
- At year-end 2014, some 114 million American adults and children (67.7 million under 65 years of age) did not have dental insurance.6
- In 2014, more than half of all children on Medicaid (18 million) didn’t get dental care.7
- In 2012, more than 2 million dental related ER visits had cost estimates up to $1.6 Billion. 8
- There are currently 5,373 Dental Health Professional Shortage Areas based on dentist to population ration of 1:5,000, with over 60% in unmet dental needs.9
- 7,826 additional dentists would be required to meet the needs of the underserved in the dental shortage areas.9
- Hispanic and African American dentists are proportionally less represented in the profession when compared to the U.S. population; African Americans represent only 3.8 percent of practicing dentists. 10
NDA REPORT FINDINGS: BARRIERS AND RECOMMENDATIONS TO CARE
The NDA recognizes that barriers to oral health care for some segments of the population are complex and cannot be solved simply from a single perspective. Two general implications rooted in the above statistics with policy implications are: financing oral health care and ensuring a diverse, sustainable oral health care workforce. To understand these implications as they reflect with NDA members and the communities they serve, a survey regarding oral health workforce issues was emailed to NDA members in 2013. The following data reflects the responses from 165 NDA respondents. 2 The survey results revealed that 62% of NDA members were Medicaid providers and 76% of respondents did not believe that they had been adequately informed about the Emerging Workforce Models (EWM). When asked,” If your state adopted credentialing for EWM providers (e.g. 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 your state allowed, reimbursed for and 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 a EWM, AND increase access to care would you consider it?” 75% (74.7%) responded “yes”.2
Research has noted that increased ethnic minority diversity in both the health care provider workforce and its leadership serving ethnic minority populations, resulted in policies, procedures and delivery systems that achieved better health outcomes.11 Findings also suggest that better health outcomes are achieved when ethnic minority populations are served by ethnic minority providers. That is why the NDA’s top priority is increasing and sustaining the number of African American dentists and African American allied oral health care professionals in the workforce in our communities.
The NDA acknowledges that there are numerous expanded workforce models, some of which are not emerging, but have been in place for over 25 years. The NDA shares the belief of the Commission on Dental Accreditation (CODA) that the merits of EWM (including dental therapists) are an issue for each state to determine based on their needs.12 The scope of practice is also purview of each state, while using CODA’s standards for dental therapy education programs as the nationally accepted educational requirements for this emerging discipline. The NDA acknowledges that although Emerging Workforce Models may be a highly relevant component to increasing access to care under certain circumstances, the complexity of access to oral health care cannot be resolved by addressing workforce alone. Social determinants must also be considered for new policy that includes multiple recommendations based on the needs of individual communities locally, nationally and globally.
While the NDA continues to research and gather a complete understanding of all of the barriers to care experienced by underserved and vulnerable populations, the organization will also formulate policy recommendations that provide evidenced-based pathways to address these barriers. This Position Statement is delivered in the context of recommendations pursuant to patient access issues and provider workforce in underserved communities.
PATIENT ACCESS ISSUES
Recommendation 1: INCREASE UNDERREPRESENTED MINORITIES IN THE ORAL HEALTH CAREERS
Recommendation 2: PRIORITIZE PREVENTION AND TOTAL HEALTH
- Develop and deliver targeted messages for Community Health and Oral Health Education.
- Mandate workforce cultural and linguistic competency reflective of the communities being served.
- Promote inter-active, inter-professional education and collaboration for patient-centered care, including physicians, nurses, pharmacists, social workers and public health specialists.
Recommendation 3: IDENTIFY AND DECREASE BARRIERS TO CARE IN UNDERSERVED COMMUNITIES.
- Support the collaboration between dental profession schools and community dental health facilities (community health centers, FQHC’s, etc.) in serving the needs of underserved communities
- Eliminate transportation barriers by matching patients with providers in closest proximity to where they live
Recommendation 4: PROMOTE RESEARCH AND DATA COLLECTION
- 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
- HRSA should support projects established in Federally Qualified Health Centers (FQHCs)
- The Office of Minority Health, NIDCR and the Minority Health Institute should support demonstration projects, which should be extended to include private practitioners who practice in underserved areas
Recommendation 5: HRSA should dedicate Title VII funding to target Under-represented minorities (URM)
Recommendation 6: Support the inclusion of adult dental services under Medicaid and Medicare with essential oral health benefits.
PROVIDER ISSUES IN UNDERSERVED COMMUNITIES
Recommendation 1: PROVIDE INCENTIVES, GUIDELINES AND PROTECTION FOR MEDICAID PROVIDERS, PUBLIC AND PRIVATE:
- Increase reimbursement for Medicaid dental providers
- Reduce administrative barriers
- Medicaid dental providers are safety-net providers and should be considered “Essential Providers”
- States should promote and reward maximizing access to care and optimal utilization of dental Medicaid programs.
Recommendation 2: HRSA should Increase Title VII funding for recruitment and scholarships for Under-represented minorities (URM), lower-income, and rural populations to attend dental professional schools and oral health training institutions.
Recommendation 3: Provide community and/or state based incentives for providers to establish practices in Dental Health Shortage Areas. (Loan repayment, low interest loans, tax credits for accepting reduced Medicaid fees, business and finance programs, etc.)
- Provide training for dentists as leaders of expanded oral health teams and inter-professional teams
- Create programs for dentists and students to learn about alternative practice delivery systems in preparation for future health 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: Recognizing the Individual State Dental Boards’ rights and responsibilities to regulate the activities of licensed Oral Health Workers, states should be encouraged to enact laws allowing 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: CONSIDER WORKFORCE DEVELOPMENT AS A DETERMINANT OF ACCESS.
- We support 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. We support the full utilization of existing oral health providers. Safety net dental providers (including private practitioners, public health facilities, and community health centers) should play leadership roles in community-based training, oversight, and regulations.
- We support quality education and training; curriculum; scope of service; and appropriate supervision consistent with the standards of the Commission on Dental Accreditation (CODA). 12 We support the inclusion of community –based practices (private practice, community health centers, Federally Qualified Health Centers) as externship sites for oral health students in training and EWM.
- We support the views of the National Academy of Medicine (formerly the Institute of Medicine), 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 competencies developed for non-dental professionals needs to be developed with input from a variety of stakeholders to ensure that they 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.)”3
- Dental Boards, as regulatory and credentialing bodies, should reflect the cultural, ethnic and gender composition of the state’s population.
Recommendation 8: Scope of practice, supervision, and workforce regulations should ensure that there are no double-standards of care in our most vulnerable and underserved populations. Evidence-based research should be available to support the safety, efficiency, effectiveness, and sustainability of all oral health delivery models.
- “Oral Health in America: A Report of the Surgeon General”, USDHHS, USPHS, 2000. P. 35
- NDA Workforce Survey Results, 2013
- Institute of Medicine and National Research Council), “Improving Access to Oral HealthCare for Vulnerable and Underserved Populations”, National Academy of Sciences, 2011
- AHRQ (Agency for Healthcare Research and Quality). 2010. 2009 National healthcare disparities report. Rockville, MD: U.S. Department of Health and Human Services.\
- National Association of Dental Plans. (2014). Dental Benefits Basics – Who. Retrieved from http://www.nadp.org/Dental_Benefits_Basics/Dental_BB_1.aspx#_ftn1
- Yarbrough, C., Vujicic, M., Ph, D., & Ph, D. (2016). Estimating the Cost of Introducing a Medicaid Adult Dental Benefit in 22 States, (March).
- Annual EPSDT Participation Report, Form CMS-416 (national) FY 2014.www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/EPSDT.html.
- Wall, M. Vujicic, “emergency department use for dental conditions to increase,” American Dental Association, Health Policy Institute Research Brief, April 2015
- Health Resource Service Administration. (2016). Designated Health Professional Shortage Areas Statistics As of January 1 , 2016 Bureau of Health Workforce Health Resources and Services Administration ( HRSA ) U . S . Department of Health & Human Services Designated Health Professional Shortage Areas St.
- American Dental Association Health Policy Institute. (2015). The Dentist Workforce – Key Facts, 2014–2015.
- Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports (Washington, D.C. : 2003), 118(4), 293–302. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1497553&tool=pmcentrez&rendertype=abstract
- Commission on Dental Accreditation, “Accreditation Standards for Dental Therapy Education Programs”. Effective Feb. 6, 2015. www.ada.org/en/coda
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
Journal of the American Association of Public Health Dentistry, Vol. 71 Special Issue: Workforce Development in Dentistry: Addressing Access to Care, Spring, 2011
Oral Health Care Workforce-Current and Proposed Providers, American Dental Hygienists Association, 2010
Community Catalyst Recommended Standards for Dental Therapy Education Programs in the United States, October 2013
Fletcher, N., “Executive Summary Oral Health and Health Care Reform: Challenges and Opportunities for Workforce Expansion”, April 15, 2011
2012 National Healthcare Disparities Report, Agency for Healthcare Research and Quality, May 2013
Alston, PA, Knapp, J., Luomanen, JC,”Who Will Tend the Dental Safety Net?”, JCDA, Feb.,2014
Creating Standards for Consistent, High- Quality Dental Therapy Education in the United States, Community Catalyst, Oct., 2013
The National Dental Association (NDA) seeks to provide continued advancement of the highest quality of oral health care and safety for the public. As a resource to key decision makers and the public on a variety of oral health issues, it is our goal to provide timely, evidenced and researched based perspectives. Position papers are reviewed periodically by our policy committee for reaffirmation, updating or expiration. An update concerning a specific recommendation in a paper is released when warranted.