2005 nc oral health summitnciom.org/wp-content/uploads/2017/07/2005dentalupdate.pdfmichael tencza,...

2005 NC Oral Health SummitAccess to Dental Care

Submitted by the North Carolina Institute of Medicine to theNC Oral Health Section of the NC Division of Public Healthwithin the NC Department of Health and Human Services

October 2005

Funded by the Association of State and Territorial DentalDirectors and the National Governors Association

Summit Proceedings and Action Plan

The full text of this report is available online atwwwnciomorg

andhttpwwwcommunityhealthdhhsstatencusdentalindexhtm

North Carolina Institute of Medicine5501 Fortunes Ridge Drive Suite EDurham NC 27713919-401-6599

NC Oral Health Section5505 Six Forks Road1910 Mail Service CenterRaleigh NC 27699-1910919-707-5480

Suggested citation

Cover photo courtesy of the Oral Health Section ofthe Division of Public Health within the NorthCarolina Department of Health and Human Services

and Action Plan Durham NC October 2005

North Carolina Institute of Medicine 2005 North Carolina OralHealth Summit Access to Dental Care Summit Proceedings

ACKNOWLEDGEMENTS

The work of this Summit would not have been possible without the generousfinancial support of the Association of State and Territorial Dental Directors andthe National Governors Association The Summit expresses thanks to its keynotespeaker Don Schneider DDS MPH a consultant in health policy and dentalhealth and former Chief Dental Officer for the US Centers for Medicare andMedicaid Services

The Summit extends special recognition to the six authors who wrotebackground pieces for the Summit Those articles served as the basis fordiscussion at the Summit as well as the foundation for this report The authorsand their background papers included ldquoIncreasing dentist participation in theMedicaid programrdquo by Mahyar Mofidi DMD MPH ldquoIncreasing the overallsupply of dentist and hygienists in North Carolina Focus on dental professionalsto practice in underserved areas and to treat underserved populationsrdquo by JohnStamm DDS DDPH MScD ldquoIncreasing the number of pediatric dentistpracticing in North Carolina expanding the provision of preventive dentalservices to young childrenrdquo by Michael Roberts DDS MScD ldquoTraining dentalprofessionals to treat special needs patients designing programs to expandaccess to dental servicesrdquo by Allen Samuelson DDS ldquoTraining dentalprofessionals to treat special needs patients designing programs to expandaccess to dental servicesrdquo by F Thomas McIver DDS MS and ldquoEducatingMedicaid recipients about the importance of ongoing dental care developingprograms to remove non-financial barriers to the use of dental servicesrdquo by DonSchneider DDS MPH These background papers can be accessed online athttpwwwcommunityhealthdhhsstatencusdentaloral_health_summithtmworkgroups

Special thanks are also due to the members of the planning committee forhelping to plan the Summit and arrange for the background papers and resourceindividuals facilitators and recorders Keshia Bailey Missy Brayboy RebeccaKing DDS MPH Faye Marley Rick Mumford DMD MPH Mike Roberts DDSMScD Paul Sebo Marla Smith Jean Spratt DDS MPH Martha Sexton TaylorRDH MBA MHA Kristie Weisner Thompson MA and Ronald Venezie DDSMS The Summit also appreciates the participation of the facilitators and

Teutsch MPH William F Vann Jr DMD PhD MS Kristen L Dubay MPPRobert Leddy DDS MPH Adrienne R Parker Pam Silberman JD DrPH JeffreySimms MSPH MDiv and Martha Sexton Taylor RDH MBA MHA

Thanks are also due to the North Carolina Department of Health and HumanServices for all of its support to the Oral Health Section

recorders Gordon H DeFriese PhD Gary Rozier DDS MPH Monica

The primary staff direction for the work of the Summit was the responsibility ofRebecca King DDS MPH Jean Spratt DDS MPH and Keshia Bailey of the OralHealth Section of the Division of Public Health a division of the NC Departmentof Health and Human Services (DHHS) They were principally responsible forleading the overall work of the Summit Primary responsibility for compilingresearch writing and editing this report were Kristen L Dubay MPP GordonH DeFriese PhD Pam Silberman JD DrPH Kristie Weisner Thompson MAand Michaela Jones PhD of the North Carolina Institute of Medicine Dataprovided by the Division of Medical Assistance were integral to the developmentof this report

Finally but most importantly the Oral Health Section extends its appreciation tothe 61 participants (listed below) who shared their time and expertise in an effortto continue evaluating the status of access to dental care in North CarolinaMany of the Summit participants are professionals who have dedicated theircareers to improving access to dental services for underserved populations andfor this we applaud them

NC Oral Health Summit Participants

Eula Alexander Oral Health SectionDivision of Public Health NCDHHS

Keshia Bailey Oral Health SectionDivision of Public Health NCDHHS

James W Bawden PhD MS DDSUNC School of Dentistry

Cindy Bolton DDS NC Dental SocietyNona I Breeland DDS MS NC Dental

SocietyTom Bridges MPH Henderson County

Health DepartmentBen Brown DDS NC State Board of

Dental ExaminersSonya Bruton MPA NC Community

Health Center AssociationHeather Burkhardt MSW NC Division

of Aging and Adult ServiceRex B Card DDS NC Dental SocietyScott W Cashion DDS MsPA NC

Academy of Pediatric Dentistry

Gordon H DeFriese PhD NC Instituteof Medicine

Rob Doherty DDS MPH GreeneCounty Health Care Inc

Kristen L Dubay MPP NC Institute ofMedicine

Wanda Greene Office of ResearchDemonstrations and Rural HealthDevelopment NC DHHS

Betsey Hardin RDH NC DentalHygiene Association

James Harrell Jr DDS NC DentalSociety

Horace Harris DDS Tri-CountyCommunity Health Center

Lisa Hartsock MPH FirstHealth of theCarolinas

Nancy Henley MPH MD FACPDivision of Medical Assistance NCDHHS

Edna R Hensey Citizens for PublicHealth

Valerie Hooks Guilford ChildDevelopment Early Head Start

Dava House Oral Health SectionDivision of Public Health NCDHHS

Johanna Irving DDS MPH WakeCounty Human Services

Rebecca King DDS MPH Oral HealthSection Division of Public HealthNC DHHS

Robert Leddy DDS MPH Oral HealthSection Division of Public HealthNC DHHS

Jim Lewis Lincoln Community HealthCenter

Michael Lewis MD East CarolinaUniversity

Jinnie Lowery MSPH Robeson HealthCare Corporation

Faye Marley NC Dental SocietyF Thomas McIver DDS MSUNC

School of DentistryMargaret McGrath New Hanover

Community Health CenterTim Mitchener DMD MPH Oral

Health Section Division of PublicHealth NC DHHS

Mahyar Mofidi DMD MPH UNCSchool of Dentistry Institute onAging

Brad Morgan DDS NC State Board ofDental Examiners

Gary Oyster DDS PA NC DentalSociety

Adrienne R Parker NC Institute ofMedicine

M Alec Parker DMD NC DentalSociety

Tom Parks Oral Health SectionDivision of Public Health NCDHHS

John Pendill DDS Oral Health SectionDivision of Public Health NCDHHS

Karen Ponder NC Partnership forChildren

Michael Roberts DDS MScD UNCSchool of Dentistry

Gary Rozier DDS MPH UNC Schoolof Public Health

Allen Samuelson DDS UNC School ofDentistry

Don Schneider DDS MPHWendy Schwade RDH Oral Health

Section Division of Public HealthNC DHHS

Pam Silberman JD DrPH NC Instituteof Medicine

Jeffrey Simms MSPH MDiv Office ofResearch Demonstrations and RuralHealth Development NC DHHS

John Sowter DDS MSc UNC Schoolof Dentistry

C Jean Spratt DDS MPH Oral HealthSection Division of Public HealthNC DHHS

John Stamm DDS DDPH MScDUNC School of Dentistry

Martha Sexton Taylor RDH MBAMHA Oral Health Section Divisionof Public Health NC DHHS

Michael Tencza MD CumberlandCounty Health Department

Monica Teutsch MPH MissionHospitals

Brian Toomey MSW Piedmont HealthServices

William F Vann Jr DMD PhD MSUNC School of Dentistry

Ronald Venezie DDS MS NCAcademy of Pediatric Dentistry

Gale Wilson NC Partnership forChildren

Charles Willson MD East CarolinaUniversity

F Terri Workman JD East CarolinaUniversity

Tim Wright DDS MS UNC School ofDentistry

Jacqueline Wynn MPH NC AreaHealth Education Center

2005 NC ORAL HEALTH SUMMITPROCEEDINGS AND PROPOSED ACTION PLAN

In 1998 the NC General Assembly asked the NC Department ofHealth and Human Services (DHHS) to study and recommendstrategies to increase access to dental services for Medicaidrecipients The Honorable David H Bruton Secretary of theNC DHHS asked the NC Institute of Medicine (NC IOM) toconvene a task force to study this issue The NC IOM TaskForce on Dental Care Access was comprised of 22 members andwas led by the Honorable Dennis Wicker Lt Governor (Chair)and Sherwood Smith Jr Chairman and CEO of Carolina Poweramp Light (now Progress Energy) (Co-Chair) The NC IOM TaskForce on Dental Care Access released its report to the NCGeneral Assembly and the NC DHHS in April 1999 It consistedof 23 recommendations which focused on

1) Increasing dental participation in the Medicaid program2) Increasing the overall supply of dentists and dental

hygienists in the state with a particular focus on efforts torecruit dental professionals to practice in underservedareas and to treat underserved populations

3) Increasing the number of pediatric dentists practicing inNorth Carolina and expanding the provision ofpreventive dental services to young children

4) Training dental professionals to treat special needspatients and designing programs to expand access todental services and

5) Educating Medicaid recipients about the importance ofongoing dental care and developing programs to removenon-financial barriers to the use of dental services

The NC IOM convened a one-day meeting in 2003 to reviewprogress on these recommendations1 In July 2003 the OralHealth Section of the NC Division of Public Health a division ofthe NC Department of Health and Human Services obtainedfunding from the Association of State and Territorial DentalDirectors and the National Governors Association to convene anNC Oral Health Summit The purpose of the Summit was toreview the 1999 NC IOM Task Force report for progress made

1 The 2003 Update of the NC IOM Task Force on Dental Care Access isavailable at httpwwwnciomorgpubsdentalhtml

2

since 20031 The NC Oral Health Summit was held on April 82005 and included 63 participants Participants includedrepresentatives of the Oral Health Section within the NCDivision of Public Health the NC Dental Society the NC StateBoard of Dental Examiners the NC Academy of PediatricDentistry the NC Dental Hygiene Association the University ofNorth Carolina at Chapel Hill (UNC-CH) School of DentistryEast Carolina University the NC Community Health CareAssociation the Division of Medical Assistance the NC Officeof Research Demonstrations and Rural Health Developmentthe NC Division of Aging the NC Partnership for Childrennon-profit dental clinics community health centers and otherinterested individuals Six of the original 22 members of the NCIOM Task Force were among the participants

The Summit participants reviewed the Task Forcersquos originalfindings and recommendations to determine if the issues werestill relevant what actions had occurred to implement the TaskForcersquos recommendations and the barriers to implementationSummit participants then suggested changes to the originalrecommendations The goal of the NC Oral Health Summit wasto identify potential strategies to improve dental care accessmdashwhether by further implementation of the original 1999 NCIOM Task Force recommendationsmdashor through new strategiesto improve access

The report begins with an overview of the problem as it existstoday (2005) followed by sections corresponding torecommendations in the original 1999 report These sectionspresent updated data (if available) related to the problemhighlight what has been done to implement therecommendations propose changes to the recommendations (ifany) and propose strategies for fulfilling them

Unlike the original Task Force which met multiple times overseveral months the Summit was a single-day event Thusparticipants did not have the ability to thoroughly analyze ordiscuss new recommendations Nonetheless the Summitprovided an opportunity to gather dental care leaders to reflectupon the actions taken and identify further steps needed toimprove access to dental services for underserved populationsThis document is the genesis for a new action plan which if

3

implemented will help ensure access to dental care for more ofthe underserved North Carolinians across the state

OVERVIEW OF THE PROBLEM IN 2005

Since the 1999 NC IOM Task Force on Dental Care AccessNorth Carolina has made significant progress towardimproving access to dental care for underserved populationsOne of the most positive steps was the increase in Medicaidreimbursement rates for dental services Following the ratechanges in 2002 and 2003 data indicate that between 2002 and2005 the price Medicaid paid per unit of dental serviceincreased 31 (from $133 in 2002 to $174 in 2005) afterdropping 8 between state fiscal years (SFY) 2001 and 20022Total expenditures also increased during this time Medicaiddental expenditures accounted for $197 million in 2004 anincrease of 89 since 2002 In fact the dental programconstitutes one of the highest growth areas in the NorthCarolina Medicaid program3

Data indicate that this increase in reimbursement has coincidedwith an increase in dentist participation in the Medicaidprogram between state fiscal years (SFY) 2001-2005 Table 1illustrates the number of private dentists who submitted aMedicaid claim to the Medicaid program during that periodBetween SFY 2001 and 2005 156 additional dentists participatedin the Medicaid program an increase of almost 10 Of thatgroup more than 50 began serving Medicaid patients sinceSFY 2004 and 80 of the growth occurred in the last two yearsWhile the absolute number of dentists who participate inMedicaid has increased the percentage of private practicingdentists who participate in Medicaid remained relatively steady(about 48-49) between fiscal years 2001 and 20043

4

Table 1 Number and percentage of private dentists participating in the Medicaid program

2001 2002 2003 2004 2005Number of private dentists whotreat Medicaid enrollees a(Percent of private dentists whopractice in NC)

1615(49)

1619(48)

1643(48) (49) ()

Total number of Medicaid recipients(total unduplicated Medicaidexcluding MQB recipients) b

1334062 1362567 1423229 1484608 1513727

Dentist to Medicaid ratio 1826 1842 1866 1881 1855a Source Loomis W Data provided by the North Carolina Division of Medical Assistance to Mahyar Mofidi February 9 2005 Attiah E Dataprovided by the North Carolina Division of Medical Assistance to Kristen Dubay August 2005b Source Attiah E Data provided by the North Carolina Division of Medical Assistance to Kristen Dubay August 2005 Fiscal year 2005 data not available at time of publishing

The 1999 Task Force on Dental Care Access Report definedldquoactive participationrdquo in the Medicaid program as those dentistswho received more than $10000 in Medicaid reimbursements ina fiscal year4 Table 2 illustrates that during SFY 2001 and 2005there was a 43 increase in the number of dentists ldquoactivelyparticipatingrdquo in the Medicaid program The largest increase inparticipating providers (20) occurred between SFY 2003 and2004 when 143 new dentists began actively participating in theMedicaid program3

Table 2 Number and percentage of private dentists ldquoactively participatingrdquo in the Medicaidprogram

2001 2002 2003 2004 2005Total number of private dentistswho practice in NC Jan-Dec (notincluding public health dentists) a

3280 3381 3414 3426

Number (percentage) of privatedentists who ldquoactively treatrdquoMedicaid enrollees July-June b

644(20)

670(20)

712(21)

855(25)

920()

a Source NC Health Professions Data System with data derived from the NC Board of Dental Examiners Chapel Hill NC Cecil GSheps Center for Health Services Research University of North Carolina 2003b Source Loomis W Data provided by NC Division of Medical Assistance Personal communication with Mahyar Mofidi February 92005 Fiscal year 2005 data not available at time of publishing

The number and percentage of Medicaid patients receivingdental services has also increased since 2001 Table 3 illustratesthe annual number and percentage of Medicaid-eligiblerecipients who had at least one dental visit during the years2001-2005 The percentage of Medicaid enrollees receivingdental services increased from 25 to 29 during this timeperiod That increase amounts to a 63 increase in the total

1686 1 771

5

number of Medicaid enrollees receiving dental servicescompared to a total increase of Medicaid recipients of 383

Table 3 Percent and number of Medicaid recipients who had at least one dental visit

2001 2002 2003 2004 2005 aTotal number Medicaid recipientswith dental coverage (totalunduplicated Medicaid excludingMQB recipients)

1124129 1264362 1459239 1522508 1552069

Number (percentage) of recipientswith a dental visit

276247(25)

327285(26)

370447(25)

417935(27)

450974(29)

Source Source Data initially collected by Mahyar Mofidi from Bill Loomis NC Division of Medical Assistance for the 2005 NC Oral Health Summit(February 2005) Updated information provided by Emad Attiah NC Division of Medical Assistance to the NCIOM (September 2005)a Data for 2005 are not final Claims may be submitted up to three months following the end of the state fiscal year June 30 2005 Therefore thesedata may increase

Sixty-two percent of Medicaid recipients receiving dental care in2005 were children below the age of 21 while 30 were adultsaged 21 or older Tables 4 and 5 illustrate the number andpercent of enrolled children under the age of 21 and the numberand percent of enrolled adults aged 21-64 that received annualdental visits Table 4 indicates that utilization rates for childrenbelow the age of 21 increased from 28 to 32 between 2001and 2005 Table 5 illustrates that utilization rates for adultsaged 21-64 rose to 28 in 2005

Table 4 Enrolled children under age 21 years getting a Medicaid dental visit

SFY 2001 SFY 2002 SFY 2003 SFY 2004 SFY 2005 c

Number of Medicaid enrolledchildren under age 21 years 551215 651061 768442 831942 881356

Number (percentage) of unduplicatedMedicaid recipients under age 21years with any dental visit a

156478(28)

195926(30)

222094(29)

261017(31)

279643(32)

At a private dentist b( of total visits)

127031(75)

150525(76)

177438(78)

211011(80)

235424(82)

At a public health facility b( of total visits)

43024(25)

47624(24)

51377(22)

52582(20)

51631(18)

Source Data initially collected by Mahyar Mofidi from Bill Loomis NC Division of Medical Assistance for the 2005 NC Oral Health Summit(February 2005) Updated information provided by Emad Attiah NC Division of Medical Assistance to the NCIOM (September 2005)a Dental visit data was provided by the NC Division of Medical Assistance and is based on total dental claims submitted for the populationb The sum of total visits at the private and public health facilities will be greater than the unduplicated number of Medicaid recipients (column 2)because some recipients receive more than one visit and may visit both a private and public providerc Data for 2005 are not final Claims may be submitted up to three months following the end of the state fiscal year June 30 2005 Therefore the totalnumber of recipient and visits may increase

6

Table 5 Enrolled adults ages 21-64 with an annual Medicaid dental visit2


Number of Medicaid-enrolled adultsages 21-64 years 371359 416199 498114 503565 491687

Number (percentage) of unduplicatedMedicaid recipient adults ages 21-64years with any dental visit a

88040(24)

99521(24)

114793(23)

124334(25)

135684(28)


85040(93)

96969(93)

109094(94)

121698(94)

129238(94)


6190(7)

6976(7)

7336(6)

7423(6)

8357(6)

Source Data initially collected by Mahyar Mofidi from Bill Loomis NC Division of Medical Assistance for the 2005 NC Oral Health Summit(February 2005) Updated information provided by Emad Attiah NC Division of Medical Assistance to the NCIOM (September 2005)a Dental visit data was provided by the NC Division of Medical Assistance and is based on total dental claims submitted for the populationb The sum of total visits at the private and public health facilities will be greater than the unduplicated number of Medicaid recipients(column 2) because some recipients receive more than one visit and may visit both a private and public providerc Data for 2005 are not final Claims may be submitted up to three months following the end of the state fiscal year June 30 2005 Thereforethe total

Similarly Table 6 indicates that dental utilization rates for olderadults enrolled in Medicaid aged 65 and over increased from16 to 20 between SFY 2001 and 2005 Although dentalutilization rates increased the SFY 2005 rate of 20 continuedto trail the averages for the other age groups

Table 6 Enrolled adults ages 65 and older getting an annual Medicaid dental visit


Number of Medicaid-enrolledadults aged 65 years and older 201555 197102 192683 187001 179026

Number (percentage) ofMedicaid recipient adults aged65 years and older with anydental visit a

31729(16)

31838(16)

33560(17)

32584(17)

35647(20)


31698(97)

31982(97)

32803(97)

33021(97)

34935(98)


871(3)

991(3)

924(3)

892(3)

888(2)


7

The majority of dental services are provided by private dentistsIn SFY 2005 82 of children under age 21 94 of non-elderlyadults age 21-64 years and 98 of older adults age 65 years orolder receiving annual dental visits were seen by privatedentists5 Further services provided by private dentists areincreasing more rapidly than those provided by public healthdentists For Medicaid recipients of all ages combined thenumber of annual dental visits provided by private dentistsincreased by 64 during the period SFY 2001-2005 compared toan increase of 4 at public health facilities A comparison byage shows that dental services at private offices increased mostfor children under the age of 21 the total number of dentalvisits provided to children in private offices increased by 85between SFY 2001-2005 compared to a 20 increase in visitsprovided to this age group by public health facilitiesUtilization rates in private dentistsrsquo practices also increased forMedicaid-enrolled adults aged 21-64 by 52 and by 10 forthose aged 65 years and older Visitation rates at public healthfacilities for those populations increased by 35 and 2respectively These data show that private dentists play acritical role in providing services for the adult population andare increasingly providing their services to children Theincrease in childrenrsquos dental care provided in private dentistsrsquooffices may indicate a positive reaction to the increasedreimbursement rates which focused primarily on services tothis younger population On the other hand dental visits forthe adult Medicaid population remain low which may be areflection of providersrsquo discouragement with lowerreimbursement levels for this population3

INCREASING DENTIST PARTICIPATION IN THE MEDICAIDPROGRAM

The original 1999 NC IOM Dental Care Access report found thatonly 16 of dentists in North Carolina ldquoactively participatedrdquo inthe Medicaid program and only 20 of Medicaid recipientsvisited dentists in 1998 Dentists seemed to have two primaryconcerns with Medicaid (1) the low reimbursement levels and(2) the high rate of broken appointments and (3) poor patientadherence among Medicaid recipients To address theseconcerns the 1999 Task Force recommended that the NCGeneral Assembly increase the Medicaid reimbursement rates

8

to attract more dentists to serve this population develop anoutreach campaign to encourage dentists in private practice totreat low-income patients and establish a Dental AdvisoryCommittee to work with the Division of Medical Assistance onan ongoing basis4 A lot has been done to implement theserecommendations however the 2005 NC Oral Health Summitfound that more work is needed The group suggested furtherreimbursement rate increases ongoing outreach efforts torecruit additional dentists into the Medicaid program andcontinued collaboration between the NC Dental Society and theDivision of Medical Assistance The following reflects the workthat has been done to implement the recommendations as wellas the additional work that is suggested to further increasedental participation in the Medicaid program

1999 Task Force Recommendation 1

Increase the Medicaid reimbursement rates for all dental procedurecodes to 80 of usual customary and reasonable charges (UCR) UCR was based on the fee schedule of the University of NorthCarolina (UNC) Dental Faculty Practice

2005 Proposed Action Plan

Increase the Medicaid reimbursement rates for all dentalprocedure codes to reflect 75 of market-based fees inNorth Carolina The Division of Medical Assistance shouldcontinue to work closely with the NC Dental Society toachieve reasonable rates using an agreed upon market-based fee schedule

In 1999 the NC IOM Task Force on Dental Care Access foundthat Medicaid paid North Carolina dentists approximately 62of the usual customary and reasonable charges (UCR) for the44 most common dental procedures for children and 42 ofUCR for other procedures4 Subsequently these rates wereincreased partially in response to actions taken by the NCGeneral Assembly and NC Division of Medical Assistance andpartially in response to a lawsuit that challenged the adequacyof the dental reimbursement rates In 2000 plaintiffsrepresenting low-income children filed a lawsuit against DHHSchallenging the adequacy of the dental reimbursement ratesThe lawsuit Antrican v Bruton was settled in 2003 As a resultof the settlement the Division of Medical Assistance increasedthe reimbursement rates for a selected list of dental procedures

9

commonly provided to children to a level of 73 of the UNCDental Faculty Practicersquos UCR The changes in dentalreimbursement rates effectively increased rates for 27 dentalservices that are also available to adult Medicaid recipientsPresumably these rate changes helped increase the willingnessof private dentists to serve the Medicaid population

Concerns and Issues Although there are clear improvements indental service utilization for the Medicaid population andparticularly for children the North Carolina Medicaidpopulation still lags behind the national averages for higherincome populations North Carolina children under the age of21 in the Medicaid population had 41 utilization rates in SFY2004 compared to rates of 494 and 652 for childrenbetween 200-400 and greater than 400 of the poverty linerespectively6 In addition some participants of the NC OralHealth Summit believe that the UCR fee schedule does notaccurately follow changes in the private sector market Theyargued that moving toward a more market-basedreimbursement fee schedule would make dentists feel morepositively about participating in the Medicaid program andthus increase access to dental care for the Medicaid population

The UNC-CH School of Dentistry fee schedule was initiallyadopted because it was one generally supported by both dentalproviders and the Division of Medical Assistance (DMA) Thisfee schedule became known as the UCR fee schedule Howevermore recently both groups have begun to discuss the potentialbenefits of a market-based fee schedule One problem with theUCR fee schedule is that there are certain services whosereimbursement rates lag behind the market dramatically whileothers are more closely aligned with or even exceed the marketaverage Developing a market-based fee schedule wouldreduce some of the major variations in payments for differentservices Market-based fee schedules have the added benefit ofautomatically indexing to adjust for inflation so that Medicaidreimbursement would keep pace with the marketplaceAlabama Michigan and Tennessee have establishedcompetitive Medicaid reimbursement rates which havesignificantly improved dental care access for the Medicaidpopulation in those states7

10

There are challenges in moving to a market-basedreimbursement fee schedule For example no data are currentlycollected at the state level about dental fees The NationalDental Advisory Service (NDAS) a national fee survey that isbased on average national costs could be used as a basis for amarket-based reimbursement rate However the market ratesin North Carolina may be lower than the national averagesTennesseersquos Medicaid program overcame this problem byreimbursing dentists for services at 75 of the average fees forthe East South Central region As a result of this reimbursementadjustment in Tennessee dental care utilization of the Medicaidpopulation almost doubled (from 24 to 47) coming muchcloser to the private market averages8 A similar change to a75 of market-based fee schedule made in South Carolina in2000 had an immediate impact on reversing the negative trendsin dental care services to children with Medicaid9

In terms of a targeted reimbursement level Summit participantsgenerally agreed that as an ultimate goal Medicaid ratesshould reflect the 75th percentile of market-based fees in NorthCarolina This means that dental reimbursement rates would beequal to or greater than the rates charged by 75 of dentists inthe state and could encourage many more dentists to participatein the Medicaid program

Subsequent to the Oral Health Summit the NC GeneralAssembly appropriated $20 million in each year of thebiennium to increase Medicaid dental rates This actuallytranslates into an approximate increase of $64 millionyearafter factoring in the federal and county share of Medicaid costsAt the time of publication of these Summit proceedings it wasnot yet clear how DMA would implement this rate increase(eg across the board rate increases or increases targeted tocertain procedures)

Application of recommendation to NC Health ChoiceThe 2005 Summit participants also discussed legislationpending in the NC General Assembly to move children birththrough age five with family incomes equal to or less than 200of the federal poverty guidelines into the Medicaid programThis was a recommendation that grew out of another NC IOMTask Force on the NC Health Choice Program (2003)10 The NCHealth Choice program provides health insurance coverage to

11

children with family incomes that are too high to qualify forMedicaid but equal to or less than 200 of the federal povertyguidelines NC Health Choice operates within certain state andfederal budgetary constraints If either the federal or statefunds run out then children can be denied coverage Because oflimited state funding the program was frozen in 2001 for eightmonths and as a result more than 34000 eligible children wereput on a waiting list for coverage In contrast Medicaid is afederal entitlement program thus all eligible children areentitled to coverage To prevent another freeze in the NCHealth Choice program the NC IOM Task Force on the NCHealth Choice Program recommended that children birththrough age five be moved from NC Health Choice to Medicaidand that the state pay the county share of this Medicaidexpansion This would guarantee that these children obtainhealth insurance coverage regardless of budgetary shortfallsand would also save funds in the NC Health Choice program inorder to cover more children11

Participants in the 2005 Dental Summit voiced concerns thataccess to dental services might be limited if the NC HealthChoice dental reimbursement rates were reduced to theMedicaid levels and recommended that Medicaid dentalreimbursement rates be increased in order to encourage theactive participation of dentists in both NC Health Choice andMedicaid Subsequent to the Oral Health Summit the NCGeneral Assembly enacted legislation to move children birththrough age five from NC Health Choice into Medicaid Inaddition to this change the NC General Assembly enactedlegislation to reduce all of the NC Health Choice providerpayments from the current reimbursement rates to the Medicaidrates by July 1 2006 for children ages 6-1812 This changeeffectively decreases the dental reimbursement rates for allchildren who were previously covered by NC Health Choice Itis important to monitor the impact of this change on access todental services for NC Health Choice participants who have inthe past had much better access to dental services than havechildren enrolled in Medicaid This is another reason toincrease Medicaid dental reimbursement rates to moreaccurately reflect market rates

12

1999 Task Force Recommendation 2 The North Carolina Dental Societies should develop an outreachcampaign to encourage dentists in private practice to treat low-income patients


The North Carolina Dental Society the Old North StateDental Society and the Division of Medical Assistanceshould continue their collaborative efforts to encouragedentists in private practice to serve low-income patientswith a particular emphasis on dentists who are not alreadyproviding services to the Medicaid population

The 1999 NC IOM Task Force Report noted that another barrierthat discouraged dentists from participating in the Medicaidprogram was the high-cancellation and ldquono-showrdquo rates amongMedicaid recipients National data from the American DentalAssociation (ADA) indicate that an average of 30 of Medicaidrecipients failed to keep their appointments in 199813 Thereport also cited that the Division of Medical Assistance made anumber of program operation changes to standardize claimforms and procedure codes automate claim submissions andpayments and eliminate prior approval requirementsHowever despite these changes stigma surrounding theMedicaid program remained Therefore it was determined thatan outreach campaign to inform dentists of these changes andencourage further participation would be a valuable step inattracting more dentists to participate in the Medicaid program

In the 2003 NC IOM update to the original report thisrecommendation was considered fully implemented The NCDental Society created an Access to Care committee thatencouraged local dental societies to serve more low-incomeMedicaid patients The NC Dental Society also providesoutreach to dental school classes to encourage theirparticipation in Medicaid after graduation The NC DentalSociety and the Division of Medical Assistance now meetregularly to develop strategies to increase dental participation14

As a result of this collaboration the Division of MedicalAssistance in consultation with the NC Dental Societydeveloped a frequently asked questions (FAQ) informationsheet about the Medicaid program to overcome negative

13

impressions of the Medicaid program and to promote positivechanges within it The NC Dental Society distributed thedocument to all its members and provided information aboutthe FAQ sheet in its newsletter the Dental Gazette In additionthe NC Dental Society and the Division of Medical Assistancehave hosted seminars and workshops to addressmisconceptions about Medicaid and to publicize the joint workand positive relationship that has developed between the twoorganizations Approximately 80 of private dentists in thestate belong to the NC Dental Society thus these outreachefforts are potentially able to reach a large group of privateproviders The Old North State Dental Society a statewidedental organization comprised largely of African American andother minority dentists also plays an important role as a modelof service to the underserved because almost all of its memberstreat Medicaid patients

Concerns and Issues These efforts are helping to achieve thegoal set forward in this recommendation Howeverparticipants at the 2005 NC Oral Health Summit felt that theseefforts should be viewed as ongoing rather than fullyimplemented as noted in the 2003 Update In particular theSummit workgroup on this topic stressed the importance oftargeting marketing strategies to dentists who are not currentlyserving Medicaid patients as much of the increase in dentalutilization since 1999 was provided by dentists who werealready serving the Medicaid population In addition it wassuggested that providing training on cultural diversity andsensitivity and respectful provider-patient interaction forproviders serving Medicaid patients could be very valuableSuch training hopefully would teach clinical and office staff totreat Medicaid patients in a non-stigmatizing manner and tobetter understand the challenges some Medicaid recipients facein accessing dental care


The Division of Medical Assistance should work with the NCDental Society the Old North State Dental Society the NCAcademy of Pediatric Dentistry the Oral Health Section of the NCDepartment of Health and Human Services the UNC-CH School ofDentistry and other appropriate groups to establish a dentaladvisory committee to work with the Division of Medical Assistance

14

on an ongoing basis The Advisory Committee should also includeMedicaid recipients or parents of Medicaid-eligible children


The Division of Medical Assistance should work with theNC Dental Society the Old North State Dental Society theNC Academy of Pediatric Dentistry the Dental HealthSection of the NC Department of Health and HumanServices the UNC-CH School of Dentistry and otherappropriate groups to continue to promote strong dentalrepresentation within the NC Physicians Advisory Group(PAG) and provide ongoing support to the PAG DentalAdvisory Committee and ensure that the Dental AdvisoryCommittee continues to include representation of Medicaidrecipients or parents of Medicaid-eligible children

In 2003 the Division of Medical Assistance added a dentist tothe Board of Directors of the NC Physicians Advisory Group(PAG) which gives guidance to the Division of MedicalAssistance (DMA) in setting medical coverage policy andcreated an independent Medicaid Dental Advisory CommitteeThe Dental Advisory Committee reports to the PAG and hasbeen particularly effective in helping to streamline DMA policy

Concerns and Issues The Summit participants noted that theessence of the 1999 recommendation has been implemented butthe actual implementation is not exactly as the recommendationsuggested because the NC Physicians Advisory Group is notconstituted in a way that would include Medicaid recipientrepresentatives This population is however represented onthe Dental Advisory Committee that reports to the PAG andthis participation seems to satisfy the spirit of the 1999recommendation Therefore participants at the 2005 NC DentalHealth Summit suggested updating the recommendation toindicate this difference and to clarify that although thisrecommendation has been implemented it should still beconsidered ongoing

15

INCREASING THE OVERALL SUPPLY OF DENTISTS ANDDENTAL HYGIENISTS IN THE STATE WITH A PARTICULARFOCUS ON EFFORTS TO RECRUIT DENTALPROFESSIONALS TO SERVE UNDERSERVED AREAS AND TOTREAT UNDERSERVED POPULATIONS

One of the major concerns addressed in the 1999 NC IOMDental Care Access Report was the limited supply of dentalprofessionals in North Carolina In 1999 the dentist-to-population ratio was 40 dentists per 10000 people and thedental hygienist-to-population ratio was 46 per 10000 In 2004the supply of dental professionals in North Carolina was stillgrim with a dentist-to-population ratio of only 41 dentists per10000 people This rate placed North Carolina 47th out of the 50states well below the national average of 58 dentists per 10000people15 This illustrates the statersquos continuing need for dentiststhroughout the state Even more staggering is the unequaldistribution of dentists across counties Four of NorthCarolinarsquos 100 counties all in the eastern part of the state haveno practicing dentists and only eight counties have a dentist-to-population ratio equal to or greater than the national average(See Map 1) Seventy-nine counties qualify as federallydesignated dental health professional shortage areas meaningthat they have a full-time-equivalent dentist to population ratioof at least 15000 or between 14000 and 15000 with unusuallyhigh needs for dental services or insufficient capacity of existingdental providers16 This shortage and the uneven distribution ofdental professionals in North Carolina are major barriers toaccessing dental care in the state

16

Map 1 Dentists per 10000 Population North Carolina 2003

Source North Carolina Health Professions Data System Cecil G Sheps Center for HealthService Research The University of North Carolina at Chapel Hill Chapel Hill 2004

Dental hygienists also play a vital role in providing dental careservices Fortunately the number of dental hygienists increased18 from SFY 1999 to SFY 2003 and the ratio of hygienists-to-population increased 6 to 48 per 10000 people17 As a resultNorth Carolina experienced a 5 increase in the ratio of dentalhygienists-to-dentists over the same period Nonetheless thisratio remains very low particularly considering the number ofdental health professional shortage areas in North Carolina


The University of North Carolina System should make it apriority to expand the number of dental students trained inNorth Carolina The goal of this initiative should be toincrease the number of dentists who practice in underservedareas of the state and who agree to treat Medicaid and otherunderserved populations

The 1999 NC IOM Task Force on Dental Care Access was notspecifically charged with estimating the extent of dentalworkforce shortage in the state However these issues arose asthe focus of those deliberations was on the lack of availabledental services both in certain geographic areas and amonglow-income people who could not obtain dental care serviceseven when covered by Medicaid The extensive shortages of

17

dental professionals in recent years is particularly problematicin rural areas

During discussion of the data on dental health professionalsparticipants in the Oral Health Summit were informed that EastCarolina University (ECU) was actively considering theestablishment of a school of dentistry in Greenville Theproposed dental school would be ldquocommunity-basedrdquo givingemphasis to the special problems of dental care access in easternand rural regions of the state Privately practicing dentists ineastern North Carolina would play an active role in the clinicaleducation of dental students trained in such a program Theproposal was for a school of dentistry modeled on thesuccessful Brody School of Medicine which has one of thehighest proportion of minority students and graduatescompared to any school of medicine in the nation as well as oneof the highest rates of graduates choosing to practice primarycare specialties and locate their practices in smallercommunities in this state Less than 7 of North Carolinadentists are from racial or ethnic minority groups More than30 of the current enrolled students in the Brody School ofMedicine represent these minority groups

There was also discussion about the possibility of expanding theUNC School of Dentistry to educate more dental studentsCurrently the UNC School of Dentistry admits approximately80 dental students each academic year The proposedexpansion would accommodate an additional 50 students for atotal enrollment of 130 students per year

Summit participants supported the goal of increasing thecapacity of the University of North Carolina System to trainadditional dentists although there was no clear consensus onhow this should be accomplished (eg through theestablishment of a new school at East Carolina University theexpansion of the UNC School of Dentistry or both)Participants understand that either approach will require newfinancial resource Nonetheless there was strong support forthe concept of trying to raise the number of dentists perpopulation closer to the national average The relative dearth ofpracticing dentists particularly among underservedpopulations and communities is one of the greatest healthresource challenges facing the state

18


Establish an Oral Health Resource Program within the Office ofResearch Demonstrations and Rural Health Development toenhance ongoing efforts to expand the public health safety net fordental care to low-income populations in NC The state cost of thisprogram would be $10 million for each year for three years


The Office of Research Demonstrations and Rural HealthDevelopment should continue its work to expand thenumber of dental safety net programs and recruit dentalprofessionals to serve low-income underserved populationsand in dental underserved areas of North Carolina To thisend it should work with the NC DHHS Oral Health Sectionto secure funding for these efforts

Although no funds were specifically allocated by the state for anOral Health Resource Program the NC Office of ResearchDemonstrations and Rural Health Development (ORDRHD)and the NC DHHS Oral Health Section worked with the Kate BReynolds Charitable Trust to expand the number of dentalsafety net programs In 1998 there were only 43 dental safetynet programs By 2003 there were 72 programs and by 2004there were 115 In addition since 1999 the NC ORDRHDrsquosdental recruitment program has grown The program recruited140 dentists and five dental hygienists to serve in dentalunderserved areas between state fiscal years 2000 and 2004 TheNC ORDRHD also began meeting with dental directors toexchange information and ideas about how to improve access todental care for low-income indigent and Medicaid patients

Concerns and Issues Despite the NC ORDRHDrsquos success inexpanding the number of dental safety net programs andrecruiting dental professionals to underserved areas the dataabove clearly indicate a serious ongoing need for dental healthprofessionals Participants at the 2005 NC Oral Health Summitfelt that the NC ORDHD and the NC Oral Health Sectionshould continue to solicit financial support to expand theseefforts In addition one participant mentioned the idea offocusing financial support on safety net clinics that offer non-traditional hours of service Many of the patients most in needof safety net services do not have employment that allows them

19

to leave work (with or without pay) for medical or dentalappointments Supporting the development of more safety netproviders offering services during non-business hours mayalleviate this barrier to access


The NC Dental Society should seek private funding from the KateB Reynolds Charitable Trust The Duke Endowment and othersources to establish a NC Dental Care Foundation for the purpose ofassuring access to needed preventive and primary dental careservices in underserved communities and populations in our state


The NC Dental Society should seek private funding fromits members and private philanthropies to support the workof the NC Dental Care Foundation for the purpose ofassuring access to needed preventive and primary dentalcare services in underserved communities and forunderserved populations in our state

The NC Dental Society established the NC Dental HealthEndowment through the NC Community Foundation andbegan funding it through its own fund-raising activities As of2004 $150000 had been raised for the Endowment The firsttwo grants were awarded to support dental care clinicsoperated by the Buncombe County Health Department and theAlamance County Health Department The Buncombe CountyHealth Center received $4800 to support routine andpreventive care for disabled children and adults and helpindigent children and adults receive care for untreated dentalneeds and pain The Alamance County Health Clinic received$4051 to purchase equipment including a rotary endodonticsystem to help treat children whose teeth would otherwiserequire extraction18

Concerns and Issues The 2005 NC Dental Health Summitparticipants were pleased with the successful development ofthe NC Dental Health Endowment and its distribution of grantsbut participants understood that the Endowment was notcurrently at a level to make significant enough grant awards toexpand access Participants expressed a desire to increaseattention to and interest in the Endowment to increase itsfunding so that more grants could be made throughout North

20

Carolina Therefore they recommended ongoing efforts tosecure funds for the Endowment


Revise the NC Dental Practice Act to permit specially trainedpublic health dental hygienists to perform oral health screenings aswell as preventive and educational services outside the public schoolsetting under the direction of a licensed public health dentist


The NC DHHS Division of Public Health Oral HealthSection should develop a data collection system todetermine the extent to which the Dental Practice Acttraining is increasing the number of oral health preventiveclinical services being provided by state and local publichealth dental hygienists

The 1999 recommendation was implemented when the NCGeneral Assembly in their 1999 session passed legislation torevise the NC Dental Practice Act to permit specially trainedpublic health dental hygienists to perform preventive clinicalservices outside the public school setting under the direction ofa licensed public health dentist (Sec 1165 of HB 168) Underthe NC Dental Practice Act public health dental hygienists mustmeet four qualifications to work under the direction of alicensed public health dentist Those requirements includeattaining at least five years or 4000 hours of clinical dentalhygiene experience fulfilling annual six-hour medicalemergency training annually renewing cardiopulmonaryresuscitation (CPR) certification and completing a NC OralHealth Section four-hour training on public health principlesand practices

As of June 2005 32 dental hygienists working in local healthdepartments and one working in a safety net special care clinichad been specially trained to provide the services outlined inthe NC Dental Practice Act under the direction of a publichealth dentist The NC Oral Health Section periodically notifieslocal health directors about the availability of training foradditional staff

In addition the NC Oral Health Section includes the content ofthe four-hour dental public health training as part of its

21

orientation program for all new NC Oral Health Section publichealth employees As a result all of the NC Oral Health Sectionpublic health dental hygienists with the adequate yearshoursof experience (36 people or about 65 of state dentalhygienists) qualify to provide preventive services under thedirection of the state public health dentists In addition the NCOral Health Section sealant program designed to reduce dentaldecay among public healthrsquos patient population was modifiedin SFY 2002-2003 to use the increased capacity of these qualifiedstate public health dental hygienists In the 2004-2005 schoolyear the majority of the 6459 sealants provided to 1911children by the NC Oral Health Section were completed byhygienists working under the direction of a public healthdentist

Concerns and Issues Although the NC Oral Health Section hasmade significant gains in fulfilling this recommendationthrough training of both state and local public health dentalhygienists there is no accounting mechanism to determine ifdental hygienists at local health departments are using thistraining to increase the level of services to patients at thoseclinics As a result the NC Oral Health Summit participantsrecommended that the NC Oral Health Section develop asystem for collecting data on the level of services local publichealth dental hygienists are providing prior to and followingtraining on the NC Dental Practice Act


The NC IOM in conjunction with the NC State Board of DentalExaminers the NC Dental Society the Old North State DentalSociety NC Dental Hygiene Association the NC Primary HealthCare Association the Dental Health Section and the NC Office ofResearch Demonstrations and Rural Health Development of theNC Department of Health and Human Services should exploredifferent methods to expand access to the services of dentalhygienists practicing in federally funded community or migranthealth centers state-funded rural health clinics or not-for-profitclinics that serve predominantly Medicaid low-income oruninsured populations The study should include consideration ofgeneral supervision limited access permits additional trainingrequirements and other methods to expand preventive dentalservices to underserved populations

22


The NC State Board of Dental Examiners is requested to re-consider the feasibility of possible arrangements underwhich dental hygienists working in migrant health centersfederally qualified health centers or community healthcenters could provide preventive dental health servicesunder the general supervision of a dentist employed bythose same organizations

Under the existing state law and dental regulations dentalhygienists employed by federally funded community ormigrant health centers state-funded rural health clinics andnot-for-profit dental clinics cannot practice under generalsupervision of a dentist Dental hygienists working inlocalstate public health clinics or dental programs mayperform preventive dental care procedures if working under thegeneral supervision of a public health dentist Summitparticipants representing other safety net organizationsexpressed a desire to have the same flexibility Theoreticallycontractual arrangements could be developed between a localhealth department (who would hire and supervise thehygienists) and other non-profit dental safety-net institutionsthat would give the hygienist the authority to practice undergeneral supervision However no such arrangements havebeen developed as of the spring of 2005 The NC State Board ofDental Examiners should re-examine this issue


Existing and any future loan repayment programs established withthe purpose of attracting dental professional personnel to work inrural or underserved areas should be accompanied by more stringentrequirements to ensure that the dentists serve low-income andMedicaid patients


The NC health professional loan repayment programshould implement a requirement for individuals who havecompleted their dental or dental hygiene education andobtained a license to practice to report every six months(during the period of obligated practice) on the place ofpractice and volume of patients served

23

The 2003 Dental Care Update reported that the NC Office ofResearch Demonstrations and Rural Health Development(ORHRD) was not given additional funding to recruit dentiststo serve in rural areas of North Carolina but the Office wasgranted flexibility in the use of existing funds for educationalloan-repayment Priority for loan forgiveness dollars wasshifted from physicians to dentists and hygienists who arewilling to work in federally qualified health centers state-sponsored rural health centers county health departments andnon-profit clinics Most of the dental sites qualify for DentalSchool Loan Repayment and travel reimbursement subsidies forpre-approved interviews The state loan repayment programwhich had a maximum repayment level of $70000 wasenhanced approximately two years ago to grant $10000 morefor bilingual providers accepting positions in areas with a highHispanicLatino population In return the providers receivingthese funds through the loan repayment program are requiredto see patients a minimum of 32 hours per week allowing atotal of eight hours per week for administrative duties Usingloan-repayment funds the NC ORDRHD has recruited 140dentists and five hygienists (since October 1999)

Preliminary research at the Sheps Center for Health ServicesResearch supports the theory that dental health professionalswho benefit from loan repayment programs and serveunderserved populations continue to do so during professionalyears following the program at a greater rate than do dentalprofessionals who were licensed at the same time but are notparticipating in a loan repayment program19 To support thisresearch and quantify the services provided to underservedpopulations through the loan repayment program Summitparticipants recommended requiring those professionalsinvolved in the program to report back biannually on thelocation of the practice and the volume of patients served


The Board of Governorsrsquo Scholarship Program and other statetuition assistance programs should carry a requirement of service inunderserved areas upon graduation

24


The Board of Governorsrsquo should vote to carry a requirementof service in underserved areas upon graduation forindividuals in the Scholarship Program In addition theBoard of Governorsrsquo should consider reallocating fundscurrently used to support special arrangements withMeharry Medical College and Morehouse School ofMedicine for the admission of North Carolina minority anddental students and applying those funds to scholarshipsupport at North Carolinarsquos own academic institutions

As reported in the 2003 Dental Care Access Update the NCState Education Foundation Assistance Authority whichmanages the Board of Governorsrsquo Scholarship programscreated a special task force in 2001 to look at this issue TheTask Force unanimously supported the idea The pay-backprovision that was discussed would allow dental students sevenyears to pay out their service requirements However theproposal needs to be voted on by the Board of Governors beforeit can be implemented and would be implemented in the 2006-2007 academic year at the earliest

The participants at the 2005 NC Oral Health Summit praised thework done so far to implement this recommendation and hopedthat the service requirement could be voted upon this year bythe Board of Governors for the earliest possibleimplementation

Another suggestion for consideration by the Board of Governorswas to potentially cancel special arrangements with bothMeherry Medical College and Morehouse School of Medicinefor the admission of North Carolina minority dental andmedical students and apply those funds to the scholarshipsupport at North Carolinarsquos own academic institutions

Concerns and Issues Participants at the 2005 NC Oral HealthSummit also discussed the idea of requiring all UNC dentalstudents covered at the in-state tuition rate to pay back theeducation subsidy provided by North Carolina taxpayersthrough their service to publicly insured patients The groupsuggested that in lieu of providing community service in publicareas students could be required for the first ten years in

25

private practice to have 10-20 of their patients covered bypublic insurance


The General Assembly should direct the NC State Board of DentalExaminers to establish a licensure-by-credential procedure thatwould license out-of-state dentists and dental hygienists who havebeen practicing in a clinical setting in other states with the intent ofincreasing the number of qualified dental practitioners in the state

In August 2002 Senate Bill 861 was signed into law (SL2002-37)to allow licensure by credentials for dentists and dentalhygienists who have practiced in another state for at least fiveyears without any disciplinary actions The NC State Board ofDental Examiners enacted rules to implement this procedureeffective January 2003 Since that time 139 dentists and 145dental hygienists have received a license by credentials Dentalprofessionals have one year from the time their application isapproved to establish a practice in North Carolina


The NC State Board of Dental Examiners should be required toevaluate the competencies required by the different regionalexaminations to determine if these examinations ensure the samelevel of professional competence required to pass the North Carolinaclinical examination The NC State Board of Dental Examinersshall report its findings to the Governor and the Presiding Officersof the North Carolina General Assembly no later than March 152001 If the Board concludes that participation in one or moreregional examinations would not ensure minimum competenciesthe Board shall describe why these other examinations do not meetNorth Carolinarsquos standards and how the quality of care provided inNorth Carolina could be affected negatively by participating in suchexaminations If the Board finds these exams to be comparableprocedures should be developed for accepting these examinations asa basis for North Carolina licensure in the year following thisdetermination

As highlighted in the 2003 Dental Care Access Update reportthe NC State Board of Dental Examiners examined the otherregional examinations and recommended against pursuing thisoption any further Since then the NC State Board of DentalExaminers has entered into discussions with its counterpartboards in other states (and members of the American

26

Association of Dental Boards) about the feasibility of a nationallicensing exam for dentists This matter is still unresolved butit is thought that North Carolina would likely participate weresuch an exam to be promulgated


The NC State Board of Dental Examiners should consider a changein the wording in the regulations governing Dental Assistants inorder to increase access to dental services for underservedpopulations

As highlighted in the 2003 Update of the Dental Care AccessReport this recommendation has been fully implemented Newrules became effective August 1 2000 with provisions for in-office training for dental assistants

INCREASING THE NUMBER OF PEDIATRIC DENTISTSPRACTICING IN NORTH CAROLINA AND EXPANDING THEPROVISION OF PREVENTIVE DENTAL SERVICES TOYOUNG CHILDREN

A 2000 Task Force report from the American Academy ofPediatric Dentistry found that between 1990 and 1998 thenumber of trained pediatric dentists in the United Statesdeclined from 3900 to 3600 This decline was attributed to alack of pediatric training programs rather than a lack of interestin pediatric dentistry training20 Fortunately between 1998 and2004 North Carolina succeeded in reversing the decliningworkforce trends of pediatric dentists in the state As of 1998there were only 47 pediatric dentists practicing in NorthCarolina but by 2004 92 pediatric dentists were active in thestate Most notably five of these dentists are engaged incommunity dental health services within health departments orMedicaid clinics In addition there are ongoing efforts toestablish a new pediatric dental residency program at theCarolinas Medical Center in Charlotte These successes areextremely important because according to the AmericanAcademy of Pediatric Dentistry pediatric dentists provide adisproportionately higher amount of oral healthcare forunderserved children and children receiving Medicaid

27


Increase the number of positions in the pediatric residency programat the UNC School of Dentistry from two per year to a total of fourper year


a) The UNC School of Dentistry should maintain its effortto train additional pediatric dental residents

b) The Department of Pediatric Dentistry within the UNCSchool of Dentistry Area Health Education Centersprogram NC Academy of Pediatric Dentistry NCDental Society Cecil G Sheps Center for HealthServices Research NC Oral Health Section within theNC Division of Public Health and other interestedgroups should convene a workgroup to study the supplyand distribution of pediatric dentists including whetherthe increased supply of pediatric dentists is keepingpace with the growth in the number of young childrenand whether the aging and retirement of pediatricdentists is likely to create a shortage of pediatric dentistsin the future

Following the 1999 Task Force recommendation that UNCChapel Hill pediatric dentist residency program be expandedfrom two-to-four NC Senate introduced a bill in the 1999session (SB 752) to appropriate $100000 per year in sustainedstate funds for three UNC School of Dentistry (SOD) pediatricdentistry residents (one per year) However Senate Bill 752was not enacted

Despite the fact that SB 752 was not enacted the Department ofPediatric Dentistry at UNC-CH still hoped to make an effort toaddress the shortage of pediatric dentists in the state Througha variety of creative financing mechanisms the Department hassucceeded in training approximately a dozen additionalpediatric dentists A few came as independently fundedinternational students and a couple dentists worked inpediatrics in conjunction with their studies in other PhDprograms at UNC

Additionally in 2003 the Department obtained a federal grantldquoResidency Training in General Dentistry andor AdvancedEducationrdquo from the Health Resources and ServicesAdministration (HRSA) to increase the number of pediatric

28

dentistry residency position by one per year for 2003-2006 Thisgrant provided firm financial support to increase the number ofresidents from six (two per year) to nine (three per year)However the grant is intended to be seed money and ifadditional funding is not secured this increase will be lost inJune of 2006 It was reported at the 2005 Summit that theDepartment hopes to continue to accept three residents peryear but secure funding remains elusive

The 2003-2006 HRSA grant is just one strategy that has beenused to increase the number of pediatric dentists in the stateAnother strategy that was already in process during theproduction of the 1999 report was to encourage UNC dentalstudents to complete pediatric residency training outside NorthCarolina and return to the state to practice

As a result of all the efforts described the number of pediatricdentists nearly doubled from 47 in 1998 to 92 in 2004 Mostnotably five of these dentists are engaged in community dentalhealth services within health departments or Medicaid clinicsConsidering this progress it was the belief of participants at the2005 NC Oral Health Summit that this success was far greaterthan expected during the 1999 Dental Care Access Task ForceIn addition there are some ongoing efforts (noted inRecommendation 14 below) to establish a new pediatric dentalresidency program at the Carolinas Medical Center inCharlotte

Concerns and Issues While the ongoing training of pediatricdentists currently may be sufficient there was concern aboutthe age of the pediatric workforce and the potential impact onpediatric dental workforce supply in the future Additionallypediatric dentists are not available throughout the state theyare largely concentrated in urban areas Thus participantsrecommended further study of the capacity of the currentsystem to produce sufficient pediatric dentists to support thegrowth in the number of young children and to examine theavailability of pediatric dental services throughout the state


The NC IOM in conjunction with the NC Academy of PediatricDentistry the UNC-CH School of Dentistry the NC AHEC programand the Dental Public Health Program within the UNC-CH School of

29

Public Health should explore the feasibility of creating additionalpediatric dental residency program(s) at ECU Carolinas HealthcareSystem andor Wake Forest University A report should be given to theGovernor and the Joint Legislative Commission on GovernmentalOperations no later than March 15 2000 The report should include thecosts of establishing additional pediatric dental residency program(s)and possible sources of funding for pediatric dental residency programssuch as state appropriations or the Health Resources and ServicesAdministration (HRSA) within the US Department of Health andHuman Services


Participants of the NC Oral Health Summit should support andassist efforts by Carolinas Healthcare System to establish a newpediatric dental residency program in North Carolina

Meetings following the release of the 1999 Task Force Reportinvolving dental faculty from East Carolina University theUniversity of North Carolina at Chapel Hill Wake ForestUniversity and Carolinas Healthcare System led to a proposalthat Wake Forest University begin a pediatric dental residencyprogram in Winston-Salem (with a plan for two residents peryear and total of four when the program was fully enrolled)However Wake Forest University was not able to recruit apediatric dentist to establish that program21

Carolinas Healthcare System which was not initially interestedin developing a pediatric dental residency program was able torecruit an American Board of Pediatric Dentistry (ABPD)-certified dentist with experience in graduate programdevelopment and plans to establish a new pediatric dentistryresidency program Carolinas Healthcare System has appliedfor program approval from the American Dental AssociationrsquosCommission on Dental Accreditation and is in the process ofsubmitting an application for a federal HRSA grant to supportdevelopment of the program However the CarolinasHealthcare System pediatric dentist who is leading thedevelopment of this residency program was planning onmoving out of the state in July 2005 As a result the residencyrsquosformation will be dependent upon finding a new programdirector

Concerns and Issues The low number of board certifiedpediatric dentists across the country may make it challenging

30

for Carolinas Healthcare System to find someone to replace theexisting program director However the participants at the NCOral Health Summit supported efforts to create new pediatricdental residency programs and thus should workcollaboratively to assist Carolinas Healthcare System in findinganother ABPD-certified dentist to lead the development of theirnew pediatric dental residency program


The Division of Medical Assistance should add ADA procedurecode 1203 to allow dentists to be reimbursed for the application ofdental fluoride varnishes and other professionally applied topicalfluorides without the administration of full oral prophylaxis

This recommendation has been fully implemented As noted inthe 2003 Dental Care Access Update Report the Division ofMedical Assistance added this procedure code as of April 11999 for Medicaid-eligible children age 0-20 years


Fund the Ten-Year Plan for the Prevention of Oral Disease inPreschool-Aged Children as proposed by the NC Dental HealthSection The goals of this effort would be to reduce tooth decay by10 in all preschool children statewide in ten years and reducetooth decay by 20 in high-risk children statewide in ten yearsThe Ten-Year Plan would expand the use of public health dentalhygienists from school-based settings to community-based settingssuch as day care centers Smart Start programs Head Start Centersand other community settings where high-risk children are locatedThe program would provide health education to mothers andcaregivers apply fluoride varnishes to young children use dentalsealants when appropriate and provide continuing educationcourses for any professional who has contact with young children


The Oral Health Section within the NC Division of PublicHealth should work with the NC Partnership for ChildrenSpecial Supplemental Nutrition Program for Women Infantsand Children (WIC) Head Start Early Head Start UNCDepartment of Pediatric Dentistry within the UNC School ofDentistry local health departments and community healthcenters child care institutions early intervention programsParent Teacher Associations the Department of Public

31

Instruction and others to develop an action plan to furtherreduce tooth decay among preschool and school-aged children

This recommendation from the 1999 NC IOM Dental CareAccess report intended to provide additional staff to the OralHealth Section (then Dental Health Section) to serve thepreschool population Over the last five years rather thanexpanding the state budget shortfalls have significantlyreduced the Oral Health Section resources to serve youngchildren

Beginning in 1998 a program called Smart Smiles was piloted inwestern North Carolina This is the program on which theprogram Into the Mouths of Babes (IMB) was later modeled andintroduced statewide The IMB program provides dentalpreventive service packages to health departments andphysiciansrsquo offices serving Medicaid-eligible children Thepackages include targeted oral health education for caregiversand a dental screening and fluoride varnish application forhigh-risk children from birth to age three Medical practitionersattempt to refer children in need of dental care to a source forcare In some areas the referrals work well while in other areasit is very difficult to find referral dentists particularly for veryyoung children with severe dental problems Collaboration isunderway with the Early Head Start program to developeducational materials for use with their clientele to help themreceive dental preventive services from the medical communityand to help them to find a dental home In March 2005 the OralHealth Section created a permanent position (77 stateappropriations 23 federal financial participation) for thetrainer and coordinator of the IMB program so that practitionertraining will continue after the development and evaluationgrant funding is exhausted

In 2003-2004 the Oral Health Section and the UNC School ofPublic Health with funding from the Centers for DiseaseControl and Prevention conducted a statewide oral heathsurvey of children kindergarten through 12th grade to evaluatethe school-based dental prevention programs The results ofthis survey will demonstrate the effectiveness of the school-based dental prevention program and it can serve as thebaseline for the preschool dental preventive program

32

Concerns and Issues Participants at the 2005 NC Oral HealthSummit suggested an action plan to continue the work done inthis area including increasing dental studentsrsquo comfort levelsin working with children and infants (one way to do this wouldinclude exposing dental students to children in healthdepartment well-baby clinics) strengthening the partnershipbetween dentistry and pediatric medicine and reviewingcurrent research on mothersrsquo use of Xylitol a sugar substitutePotential collaborative partners include the NC Partnership forChildren Special Supplemental Nutrition Program for WomenInfants and Children (WIC) Head Start Early Head Start UNCDepartment of Pediatric Dentistry local health departments andcommunity health centers schools Parent Teacher Associationsearly intervention programs and other child care institutions


The NC Dental Society the NC Academy of Pediatric Dentistrythe Old North State Dental Society the NC Pediatric Society andthe NC Academy of Family Physicians should jointly review andpromote practice guidelines for routine dental care and preventionof oral disease as well as guidelines for referring children for specificdental care so as to provide all children with early identificationand treatment of oral health problems and to ensure that their caregivers are provided the information necessary to keep theirchildrenrsquos teeth healthy

As discussed above in Recommendation 16 this has beenpartially implemented by the Into the Mouths of Babes (IMB)program The IMB steering committee has evaluated theprogram and is encouraging its expansion through theparticipation of more physicians However additional work isneeded to develop a dental periodicity schedule for children


The Division of Medical Assistance should develop a new servicepackage and payment method to cover early caries screeningseducation and the administration of fluoride varnishes provided byphysicians and physician extenders to children between the ages ofnine and 36 months

This recommendation was fully implemented as part of the Intothe Mouths of Babes program as noted above inrecommendation 16

33


Support the enactment of House Bill 905 or Senate Bill 615 whichwould expand NC Health Choice to cover sealants fluoridetreatment simple extractions stainless steel crowns andpulpotomies

This recommendation was fully implemented The 2003 DentalCare Access Update noted that NC Health Choice wasexpanded to cover dental sealants fluoride treatment simpleextractions stainless steel crowns and pulpotomies Thisprovision was enacted as part of the 1999 Appropriations Act(Sec 119 of HB 168)

TRAINING DENTAL PROFESSIONALS TO TREAT SPECIALNEEDS PATIENTS AND DESIGNING PROGRAMS TOEXPAND ACCESS TO DENTAL SERVICES

Dental professionals face a unique challenge when treatingspecial needs patients because each patient is different andthus there is no common process by which all special needspatients should be treated Some patients can be served in atraditional private practice environment needing no additionaltime or services while others must be served at their residencerequire specific facility capabilities andor take significantlylonger to serve than traditional patients

Historically many special needs patients received servicesthrough residential institutions where they lived As thenumber of institutional programs for special needs populationshas decreased and those individuals are integrated intocommunities across the state accessing healthcare needsincluding oral health needs through existing health resourceshas become a greater challenge

Barriers to accessing dental health services arise from a varietyof factors within the special needs community One of theproblems is that dental health is often not seen as an importantcomponent of overall healthcare for the special needsindividual Special needs children may lack appropriate dentalcare if oral health is not specifically outlined in the overallhealth plan for the child Caregivers may be overwhelmed by

34

other health and developmental concerns and not realize theimportance of oral healthcare prevention techniques until aproblem occurs22 This is a similar situation for frail adults orother people with poor health living in nursing homes whosecaregivers may not understand the importance of oral health tooverall health In fact studies find that elderly subjects withmissing teeth have a lower intake of nutrients than individualswith all of their teeth and oral health can significantly impactnutritional deficiencies Poor oral health dry mouth(xerostomia) and inability to chew sufficiently (inadequatemasticatory function) are three factors that contribute tonutritional deficiencies among nursing home populations23

The dental health of special needs individuals is also affected bytheir own ability or lack thereof to actively participate inpreventive oral care Problems that prevent some individualswith special health needs from accessing dental services includefrequent illnesses difficulty scheduling appointments andinadequate transportation

Those living in nursing homes face other challenges Many livethere because they can no longer complete common activities ofdaily living on their own In fact the National Nursing HomeSurvey found that 97 of residents need assistance bathing87 dressing 58 toileting and 40 eating Therefore it is notsurprising that many nursing home residents would alsorequire assistance performing oral hygiene activities In thesesettings dental care professionals and licensed practical nurses(LPNs) usually develop an oral care plan for residents and thenurse aides carry out the plan Nurse aides provide 90 ofdirect patient care (including oral care) However many nurseaides lack training in oral health Further there may not be anemphasis on oral health within the nursing home orstandardization in how to perform oral assessments Residentsalso may exhibit physical and behavioral reactions such asbiting toothbrushes and refusing care which make it difficult tocomplete proper oral healthcare In-service training programstry to address these problems by educating nursing home staffabout oral health examinations and daily care Nurse aideswho receive training are able to perform daily oral care betterand refer patients to a dental provider more efficiently Alsostudies indicate that the benefits of oral health training

35

programs may stay in effect for as long as three years butperiodic updating is recommended23

Many dentists are unwilling to treat patients with special healthneeds Some dentists lack training in providing services to thispopulation some are not comfortable interacting with specialneeds populations and some find it disruptive to theirconventional dental practices and infeasible financially Ninety-nine percent of special needs patients are Medicaid recipientsTherefore low Medicaid reimbursement rates coupled with theextra time it sometimes takes to treat people with specialhealthcare needs deter some dentists from serving thispopulation In addition some patients with special healthcareneeds have equipment needs that private practices are not ableto address Even dentists that treat special needs patients mayrefuse to treat severely uncooperative or disruptive patientsbecause they lack the expertise or resources needed for thesepatients23


The UNC-CH School of Dentistry the NC AHEC system and theNC Community Colleges that offer educational programs fordentists dental hygienists and dental assistants should intensifyand strengthen special-care education programs to trainprofessionals on child management skills and how to provide qualityoral health services to residents and patients in group homes long-term care facilities home health and hospice settings


a) The UNC-CH School of Dentistry the NC AHECsystem and the NC Community Colleges that offereducational programs for dentists dental hygienists anddental assistants should intensify and strengthenspecial-care education programs to train professionalson child management skills and how to provide qualityoral health services to residents and patients in grouphomes long-term care facilities home health andhospice settings

b) The Division of Medical Assistance should enhance theMedicaid reimbursement for patients with disabilitiesor behavioral problems that require additional time totreat

36

The 2003 NC IOM Dental Report Update considered thisrecommendation completed highlighting a number ofprograms within the UNC-CH School of Dentistry that providedental and dental hygiene students with training and skills forworking with special needs populations such as child behaviormanagement and dental care for patients with disabilitiesThese programs are an important step in preparing dentalprofessionals to work with special needs populations and arecritical to implementing the recommendation above Howeverparticipants at the 2005 NC Oral Health Summit expressedconcern that it is difficult to determine the impact of thistraining without collecting data to measure the level of servicethese new professionals provide to special needs populationsMost of the data that are collected focus on dental care for thepediatric population In fact data are not being collected toeven determine if these students are serving Medicaid patientswhen they begin their professional positions Therefore theSummit participants suggested developing a system to collectdata on students receiving oral health training for special needspatients and their professional services to the Medicaid andspecial needs populations

Further it was suggested that special needs training for dentalstudents and practicing dentists should in addition to clinicalinstruction incorporate techniques for scheduling andintegrating patients within a more traditional patient baseSkills such as managing and scheduling time for special needspatients developing a comfort level in treating special needspatients and learning to make the office comfortable fortraditional patients and special needs patients concurrently areintegral to successfully treating special needs patients in aprivate practice environment Treating some special needspatients may take longer than traditional appointments and ifdentists are unfamiliar with how to schedule appropriately itcould prevent them from treating these patients in theirpractices One recommendation for addressing this issue wasfor dentists to set aside a half-day to serve only patients withspecial needs It was also suggested that concentrated specialneeds clinics could be designed to provide the equipment andfacility needs that may be unavailable in most dentistsrsquo officesand dentists could be encouraged to provide part-time servicesin those clinics This could also eliminate dentistsrsquo concerns that

37

North Carolina ProgramsServing Special NeedsPatients

Carolinas Mobile DentistryProvides dental care to 1500nursing home residents inthe Charlotte area

Access Dental Care Serves over1500 patients in Guilford andRandolph Counties

Special CareGeriatric DentalClinic This specialcaregeriatric clinic providesdental services to between600 and 1000 patients eachyear

Fellowship Program in GeriatricDentistry This DukeUniversity program is able toserve between 450 and 500geriatric patients annually

UNC Hospitals Dental ClinicProvides inpatient andoutpatient services mostlyfor medically compromisedgeriatric ill pediatricpatients and operating roomcases

Private practitioners A fewprivate practitionersspecialize in geriatrics buttheir practices are not limitedto that population

Individual hospital-basedprograms Moses ConeWesley Long CommunityHospital UNC Chapel Hill

Mission Childrens DentalProvides out-patient servicesfor medically compromisedand developmentallydisabled pediatric patients

traditional patients may feel uncomfortable around specialneeds patients in the private practice offices

Concerns and Issues Reimbursement rates are a seriousimpediment to expanding the number of dentists willing toserve special needs populations For many serving thispopulation would require more time to treat and wouldresult in a lower reimbursement rate per hour than from aprivately insured client Until this discrepancy inreimbursement is at least partially mitigated it will be verydifficult to attract more dentists to serve the special needspopulation One recommendation for addressing this issueis the development of additional Medicaid reimbursementcodes for services to disabledspecial needs populationsA medical and behavioral code could be tied to the medicaldiagnosis and time required to serve these special needspatients but this would need to be monitored to ensure noabuse (eg ldquoupcodingrdquo) in the use of this code Summitparticipants discussed developing a pilot program to serveas a regional resource for patients with special physicalmental and medical conditions The pilot could be cost-based and help the Division of Medical Assistance and theGeneral Assembly identify the true costs of care for thesespecial needs populations


Support the development of statewide comprehensive careprograms designed to serve North Carolinarsquos special care anddifficult-to-serve populations

Since the release of the NC Institute of Medicinersquos report onDental Care Access in April 1999 there have been anumber of agencies that have established programs toprovide dental services to institutional and other difficult-to-serve populations (see sidebar for examples) Mobiledental care programs have been helpful in reaching specialneeds patients who face obstacles that keep them fromgetting to the dentistrsquos office however these dental vansare not available in all parts of the state Additional work isneeded to ensure that these programs are availablestatewide

38

Currently the Sheps Center at UNC-Chapel Hill has fundingfrom the NC Council on Developmental Disabilities to conducta three-year demonstration project aimed at improving thequality of medical care for adults with development disabilitiesAlthough not currently in the scope of this funding the ShepsCenter would like to extend the projectrsquos focus to dental careCare coordination for people with disabilities in the program isprovided by care managers through Local Management Entities(LMEs) or through Community Care of North Carolina (CCNC)These staff could help train caregivers on how to improve oralhygiene in the home environment

Concerns and Issues Participants at the 2005 NC Oral HealthSummit thought it would be useful to develop a publicationoutlining state-run and independent organizations thatcurrently provide dental services to special needs patientsThese organizations could then be used as models for initiatingnew pilot programs This resource could also provide evidencefor which dental services are most in need of increases inreimbursement rates

The group also felt that more collaboration and informationsharing between physicians and dentists could accelerate thetreatment process for special needs patients Medication andhealth histories would help dentists determine what type ofbehavior they may expect from a patient and if it is possible touse anesthesia if necessary Additionally physicians familiarwith dental health problems could identify oral health needsand refer patients to a dentist when needed Similarly therecould be consideration of expanding the role of dentalhygienists to provide prevention education and screening ofspecial needs patients in a physicianrsquos office or nursing homeThis could emulate the work being done with children andfluoride varnish (See recommendation 18)

39

EDUCATING MEDICAID RECIPIENTS ABOUT THEIMPORTANCE OF ONGOING DENTAL CARE ANDDEVELOP PROGRAMS TO REMOVE NON-FINANCIALBARRIERS TO THE USE OF DENTAL SERVICES

Ongoing dental care can have a significant positive impact onthe oral health of patients Therefore emphasizing this value toMedicaid patients and encouraging them to access regularpreventive dental services should be a major goal of the NCDivision of Medical Assistance (DMA) When Medicaidrecipients enroll in the Medicaid program they receive ahandbook with an explanation of the programrsquos benefitsUnfortunately the handbook is very long and many people donot read it fully As a result recipients are not always aware ofthe dental services available to them under Medicaid

Lack of information is just one of the non-financial barrierskeeping Medicaid patients from accessing care Other problemsinclude finding a dentist willing to serve Medicaid patientsovercoming transportation challenges and an inability to leavework during normal work hours to visit a dentist


The Division of Medical Assistance in conjunction with the NCDental Health Section of the NC Department of Health and HumanServices should develop or modify community education materialsto educate Medicaid recipients about the importance of ongoingdental care


a) The NC Oral Health Section within the NC Division ofPublic Health should convene a committee includingrepresentatives of the Division of Medical Assistance NCDental Society Medicaid recipients local healthdepartments and other interested groups to identifyeducational materials and develop an ongoing socialmarketing campaign to educate Medicaid recipients aboutthe importance of ongoing preventive dental care Thecommittee should also work to create referral systems thatwould help Medicaid recipients identify dentists willing totreat them

b) The Division of Medical Assistance should develop a web-based referral database that is available to the public that

40

identifies dentists who accept Medicaid patients indicates ifthey are currently accepting new Medicaid patients andpermits dentists to update data about their practice and theiravailability to serve these patients online

No action was taken to implement the 1999 recommendationIn order to implement this recommendation the Division ofMedical Assistance (DMA) will need to determine whicheducational materials are most appropriate the best process fordistributing those materials to recipients and how to providereferral services

The 2005 NC Oral Health Summit participants recommendedevaluating existing educational materials from the NationalInstitutes of Health National Institute of Dental Research theNational Center for Child and Maternal Health other states theNC Dental Society and the NC Oral Health Section todetermine how to best develop materials that are culturally andlinguistically appropriate for the Medicaid populations Inaddition participants recommended developing other modelsof communication with patients such as CDs and the InternetInformational videos could be used in the offices of localdepartments of social services physicians Head Start and WICprograms Additional written materials about the importanceof oral health and good dental care could be provided tomothers at WIC screenings and by the NC Baptists Menrsquosmedical-dental buses which periodically travel to every countyto provide medical and dental services to special needs groupsin the state Currently DMA provides written materialsthrough quarterly and monthly mailings

In addition participants in the NC Oral Health Summitrecommended that the Division of Medical Assistance develop areferral database that patients could access to find dentalproviders in their local areas This system should be both web-based and linked to CARE-LINE the existing NC DHHSinformation and referral hotline In addition dentists should beencouraged to update their information to indicate if they areaccepting new patients Certain counties such as Wake Countyhave developed referral lists of dentists and keep them up-to-date This local model could be used as an example at the statelevel

41

In order to achieve the goal outlined in this recommendationparticipants recommended that the NC Oral Health Section takethe lead in developing a committee including DMA the NCDental Society Medicaid recipients local health departmentsand other interested groups to identify education materials andreferral systems that could be effective in serving the Medicaidpopulations


The NC Division of Medical Assistance should pilot test dental carecoordination services to improve patient compliance and enhancethe ability of low-income families and people with special healthcareneeds to overcome non-financial barriers to dental care TheDivision of Medical Assistance should evaluate the program todetermine if care coordination increases utilization of dental careservices The evaluation should be reported to the Governor and theNC General Assembly no later than January 15 2001


The Division of Medical Assistance should continue toexplore and pilot test dental care coordination servicesthrough the use of Health Check coordinators CommunityCare of North Carolina (CCNC) case managers or othermodels to improve patient compliance and enhance theability of low-income families and people with specialhealthcare needs to overcome non-financial barriers todental care The Division of Medical Assistance shouldevaluate the program to determine if care coordinationincreases utilization of dental care services

As reported in the 2003 Update on Dental Care Access theDivision of Medicaid Assistance (DMA) tested dental carecoordination through Health Check coordinators in somecounties throughout the state

There are currently insufficient care coordinators (througheither Health Check or CCNC) to provide dental carecoordination for all Medicaid recipients Thus participants inthe NC Oral Health Summit suggested that dental carecoordination be provided to Medicaid patients who have anenhanced risk for dental caries or for complications from dentaldisease Populations with such enhanced needs for dentalservices include those with a history of dental disease diabetesheart disease pregnant women low-birth weight babies

42

children who have chronic conditions special needspopulations people using the emergency department for dentaldisease and nursing homeinstitutionalized patients Medicaidpatients should be targeted proactively for case managementservices based on their risk status or targeted retroactivelyaccording to whether or not the patient did not follow thedental periodicity schedule or both

The participants of the Oral Health Summit thought this modelshould be tested through pilot programs before implementingit statewide One possible model would use Health Checkcoordinators to identify high-risk children through the fluoridevarnish program They could help schedule appointments withreferral dentists and arrange transportation This model existsin some North Carolina counties but funding is not available toexpand it further Another model is to add dental servicecoordination to the medical service functions of CCNC casemanagers Case managers could provide referrals and supportin finding dental homes for children and adults much like themedical home model now employed in pediatric medical careRecommendation 17 which suggested developing a dentalperiodicity schedule could also be used to guide Medicaidrecipientsrsquo use of dental services Medicaid recipients at highestrisk could then be identified for case management servicesbased on diagnostic codes on their medicaldental claims or ifthey do not follow the periodicity schedule The dental andmedical communities will need to work with the Division ofMedical Assistance to be sure that a screening periodicityschedule is kept up-to-date All efforts in this area will require awide range of partners including North Carolina dental healthprofessionals the NC Pediatric Society the CCNC networksHealth Check coordinators school health nurses and otherhealth providers

Concerns and Issues Developing a dental home program forMedicaid recipients will be challenging because there currentlyare not enough dentists actively participating in the Medicaidprogram Unlike physicians dentists do not receive anadministrative per member per month fee to manage all of thepatients oral health needs While participants thought that thisidea was worth exploring it would be difficult to implementgiven the current level of dentist participation in MedicaidThis recommendation would need to be coupled with a

43

reimbursement rate increase to encourage more dentists toparticipate in Medicaid and agree to serve as the recipientrsquosdental home

44

ENDNOTES 1 The NC IOM held one-day reviews in 2001 and 2003 to determine what action hadoccurred on the Task Forcersquos recommendations These updates can be found athttpwwwnciomorgpubsdentalhtml The NC Oral Health Summit (2005) was afurther review of progress made on the original recommendations2 North Carolina Division of Medical Assistance 20053 Mofidi Mahyar Background Paper for Recommendation Section I Increasingdentist participation in the Medicaid program North Carolina Oral Health SummitApril 8 2005 Chapel Hill NC Available athttpwwwcommunityhealthdhhsstatencusdentalimagessummitBackground_Mofidipdf Accessed July 20054 North Carolina Institute of Medicine Task Force on Dental Care Access Report tothe North Carolina General Assembly and to the Secretary of the NC Department ofHealth and Human Services North Carolina Institute of Medicine Durham NCMay 1999 Available at httpwwwnciomorgprojectsdentaldentalhtml5 Source Loomis W Data provided by North Carolina Division of MedicalAssistance Personal communication between Mahyar Mofidi and William LoomisFebruary 9 20056 American Dental Association State and community models for improving accessto dental care for the underserved-A white paper Chicago IL American DentalAssociation 20047 American Dental Association State and community models for improving accessto dental care for the underserved-A white paper Chicago IL American DentalAssociation 20048 Ibid9 Nietert J Bradford W Kaste L The Impact of an Innovative Reform to the SouthCarolina Dental Medicaid System Health Research and Educational Trust200540(4)107810 NC Health Choice 2003 Report of the North Carolina Institute of Medicine TaskForce on the NC Health Choice Program Durham NC North Carolina Institute ofMedicine Feb 2003 Available online at httpwwwnciomorgpubschildhtmlAccessed July 200511 Studies suggest that children enrolled in Medicaid actually receive better carecoordination through Medicaid care coordinators and Community Care of NorthCarolina than those enrolled in NC Health Choice An independent evaluation ofNC Health Choice and Medicaid showed that children under age five whosubsequently enrolled in NC Health Choice received fewer well-child check-upsonce on NC Health Choice than while on Medicaid Slifkin RT et al Assessing theeffects of the North Carolina Health Choice Program on beneficiary access to careFinal Report Submitted to the NC Division of Medical Assistance Sept 25 200112 Sec 1022 of Chapter 276 of the 2005 Session Laws13 North Carolina Institute of Medicine Task Force on Dental Care Access DurhamNC NC Institute of Medicine 1999 Available athttpwwwnciomorgpubsdentalhtml Accessed July 200514 Participants in the Oral Health Summit lauded the work of Medicaid DentalDirector Dr Ronald Venezie for his collaboration with the NC Dental Society anddevelopment of a strong relationship between the two organizations It wasemphasized that this type of positive collaborative leadership role is integral to thecontinued promotion and expansion of serving the Medicaid population throughprivate providers15 American Dental Association Health Policy Resources Center Telephone inquiryby John Stamm DDS DDPH MScD January 2005

45

16 North Carolina Health Professions Data System Cecil G Sheps Center for HealthService Research The University of North Carolina at Chapel Hill Chapel Hill200417 North Carolina Health Professions Data System Cecil G Sheps Center for HealthService Research The University of North Carolina at Chapel Hill Chapel Hill2004 Available at httpwwwshepscenterunceduhp Accessed July 200518 Foundation News Spring 2005 North Carolina Community FoundationAvailable athttpwwwnccommunityfoundationorgpublications05_news_springpdf AccessedMay 200519 Konrad R Sheps Center for Health Services Research University of NorthCarolina at Chapel Hill Telephone inquiry by NC Institute of Medicine July 200520 Survey of advanced dental education American Dental Association SurveyCenter 1993 1999 200321 The American Dental Association requires that all program directors be board-certified There are only 3783 board-certified pediatric dentists in the nation andnot all of them are practicing22 Eden-Piercy GVS Blacher JB Eyman RK Exploring parentsrsquo reaction to theiryoung child with severe handicaps Mental Retard 198624285-29123 Samuelson A Background Paper for Recommendation Section IV Training dentalprofessionals to treat special needs patients designing programs to expand access todental services North Carolina Oral Health Summit April 8 2005 Chapel Hill NCAvailable athttpwwwcommunityhealthdhhsstatencusdentalimagessummitBackground_Samuelsonpdf Accessed September 2005

NC Institute of Medicine November 2005 ERRATA SHEET This document outlines an error found in the 2005 North Carolina Oral Health Summit Access to Dental Care report On page 9 the document incorrectly reads ldquoNorth Carolina children under the age of 21 in the Medicaid population had 41 utilization rates in SFY 2004 compared to rates of 494 and 652 for children between 200-400 and greater than 400 of the poverty line respectivelyrdquo Updated data indicate that state fiscal year 2004 utilization rates (the unduplicated number with a full dental visit) for the Medicaid population under the age of 21 years was 31 In SFY 2005 the utilization rate of this population as of September 20051 was 322 Therefore the corrected information should read ldquoNorth Carolina children under the age of 21 years in the Medicaid population had 31 utilization rates in SFY 2004 compared to rates of 494 and 652 for children between 200-400 and greater than 400 of the poverty line respectivelyrdquo

1 Data for 2005 were not final as of September 2005 Claims may be submitted up to three months following the end of the state fiscal year June 30 2005 Therefore the total number of recipients and visits may increase 2 Data initially collected by Mayhar Mofidi from Bill Loomis NC Division of Medical Assistance for the 2005 NC Oral Health Summit (February 2005) Updated information provided by Emad Attiah NC Division of Medical Assistance to the NC Institute of Medicine (September 2005)

The full text of this report is available online atwwwnciomorg

andhttpwwwcommunityhealthdhhsstatencusdentalindexhtm

North Carolina Institute of Medicine5501 Fortunes Ridge Drive Suite EDurham NC 27713919-401-6599

NC Oral Health Section5505 Six Forks Road1910 Mail Service CenterRaleigh NC 27699-1910919-707-5480

Suggested citation

Cover photo courtesy of the Oral Health Section ofthe Division of Public Health within the NorthCarolina Department of Health and Human Services

and Action Plan Durham NC October 2005

North Carolina Institute of Medicine 2005 North Carolina OralHealth Summit Access to Dental Care Summit Proceedings

ACKNOWLEDGEMENTS
















































































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1686 1 771

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156478(28)

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127031(75)

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43024(25)

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52582(20)

51631(18)


6





88040(24)

99521(24)

114793(23)

124334(25)

135684(28)


85040(93)

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109094(94)

121698(94)

129238(94)


6190(7)

6976(7)

7336(6)

7423(6)

8357(6)







31729(16)

31838(16)

33560(17)

32584(17)

35647(20)


31698(97)

31982(97)

32803(97)

33021(97)

34935(98)


871(3)

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1334062 1362567 1423229 1484608 1513727





3280 3381 3414 3426


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670(20)

712(21)

855(25)

920()



1686 1 771

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1124129 1264362 1459239 1522508 1552069


276247(25)

327285(26)

370447(25)

417935(27)

450974(29)







156478(28)

195926(30)

222094(29)

261017(31)

279643(32)


127031(75)

150525(76)

177438(78)

211011(80)

235424(82)


43024(25)

47624(24)

51377(22)

52582(20)

51631(18)


6





88040(24)

99521(24)

114793(23)

124334(25)

135684(28)


85040(93)

96969(93)

109094(94)

121698(94)

129238(94)


6190(7)

6976(7)

7336(6)

7423(6)

8357(6)







31729(16)

31838(16)

33560(17)

32584(17)

35647(20)


31698(97)

31982(97)

32803(97)

33021(97)

34935(98)


871(3)

991(3)

924(3)

892(3)

888(2)


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1615(49)

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1334062 1362567 1423229 1484608 1513727





3280 3381 3414 3426


644(20)

670(20)

712(21)

855(25)

920()



1686 1 771

5




1124129 1264362 1459239 1522508 1552069


276247(25)

327285(26)

370447(25)

417935(27)

450974(29)







156478(28)

195926(30)

222094(29)

261017(31)

279643(32)


127031(75)

150525(76)

177438(78)

211011(80)

235424(82)


43024(25)

47624(24)

51377(22)

52582(20)

51631(18)


6





88040(24)

99521(24)

114793(23)

124334(25)

135684(28)


85040(93)

96969(93)

109094(94)

121698(94)

129238(94)


6190(7)

6976(7)

7336(6)

7423(6)

8357(6)







31729(16)

31838(16)

33560(17)

32584(17)

35647(20)


31698(97)

31982(97)

32803(97)

33021(97)

34935(98)


871(3)

991(3)

924(3)

892(3)

888(2)


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1124129 1264362 1459239 1522508 1552069


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327285(26)

370447(25)

417935(27)

450974(29)







156478(28)

195926(30)

222094(29)

261017(31)

279643(32)


127031(75)

150525(76)

177438(78)

211011(80)

235424(82)


43024(25)

47624(24)

51377(22)

52582(20)

51631(18)


6





88040(24)

99521(24)

114793(23)

124334(25)

135684(28)


85040(93)

96969(93)

109094(94)

121698(94)

129238(94)


6190(7)

6976(7)

7336(6)

7423(6)

8357(6)







31729(16)

31838(16)

33560(17)

32584(17)

35647(20)


31698(97)

31982(97)

32803(97)

33021(97)

34935(98)


871(3)

991(3)

924(3)

892(3)

888(2)


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88040(24)

99521(24)

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924(3)

892(3)

888(2)


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2005 nc oral health summitnciom.org/wp-content/uploads/2017/07/2005dentalupdate.pdfmichael tencza,...

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