Slide 1: Ryan White CARE Act Dental Reimbursment Program (DRP) 2003 Data

Image: Dentist with Patient in Chair

Slide 2: Program Overview

• The Dental Reimbursement Program (DRP) under Part F of the Ryan White CARE Act is intended to help accredited pre-doctoral education, dental hygiene schools and post-doctoral dental education programs defray their non-reimbursed costs of providing oral health care to individuals with HIV.
  
• The data illustrated here are those for which 2003 program funds were awarded to defray the non-reimbursed oral health service costs incurred during the 2001 - 2002 service year.

• A total of 64 eligible institutions applied for reimbursement, and their data are illustrated in these slides

Slide 3: Purpose

• To assist with defraying the rising non-reimbursed costs faced by dental education institutions providing care to individuals with HIV.
• To improve access to oral health care for individuals with HIV.
• To ensure that dental and dental hygiene students and dental residents receive the most current training in the management of oral health care for individuals with HIV.
  

Slide 4: Characteristics of Applicants

The 64 DRP applicants who submitted data were located in 20 states, the District of Columbia, and Puerto Rico. Of these programs:

• 29 were Pre-doctoral Dental School Programs
  Institutions of higher learning that educate and train students in the field of dentistry and provide oral health services to patients, including those with HIV.

• 35 were Postdoctoral Dental Residency Programs
  Schools of dentistry, hospitals, or public or private institutions that offer training in the specialties of dentistry, advanced education in general dentistry, or are sites of general dental practice residencies.

Slide 5-8: Program Attributes

Image: Map showing locations of post-doctoral and pre-doctoral programs.

Several of the programs have special attributes that distinguish them among dental programs:

• DRP applicants provided services in on-site dental clinics, multiple off-site satellite clinics and community-based facilities.
• DRP grantees have dental clinics that are located in close proximity to Infectious Disease Clinics and they collaborate in the care of HIV-positive patients.
• A few DRP grantees have clinics that are dedicated to specific populations, such as children, the elderly, or disadvantaged populations, and most offer a broad range of oral health services.
  
• Most DRP applicants are involved in a number of collaborative activities with other health programs and agencies, such as State and local agencies and other Ryan White CARE Act funded programs. Many also participate in the development of the Statewide Coordinated Statement of Need (SCSN).
• Outreach is an integral part of most DRP programs, with special emphasis on dental care for medically compromised individuals and patients with special needs. Some offer mobile dental units to substance addiction programs, homeless shelters and public health clinics. Many others participate in patient and provider education programs affiliated with AIDS Education and Training Centers (AETCs). Some offer free dental screenings to children while others participate in referral relationships with community-based agencies and local practitioners.
• DRP applicants pride themselves on their commitment to caring for special populations such as the poor who rely on public assistance, those who have been denied services elsewhere, and pregnant women who are HIV positive.
  
• Many adjust their services to overcome fundamental barriers to accessing care. They provide care in mobile clinics and locations in underserved communities. Others provide much needed oral health care services for underserved rural populations, while many others provide transportation services, extended clinic hours, Saturday appointments and 24-hour on-call residents for dental emergencies.
• A couple of DRP applicants have started offering unique services designed to connect affiliated sites and thereby extend training to providers and services to patients. Telemedicine programs, distance learning and videoconferencing capabilities are being developed within community-based sites.
  
• Many institutions have staff reflective of the diverse population of the patients they treat and others provide translation services to overcome language barriers.
• An important component of many programs is the availability of dental specialists. Some offer specialized services such as trauma care for patients with maxillofacial injuries. Others provide lymph node biopsies for HIV-related TB, lymphomas and other opportunistic infections, as well as comprehensive cancer surgery and coordination of radiation and chemotherapy.

Slide 9: Patient Characteristics

• Dental Reimbursement Program applicants reported serving 27,885 individuals with HIV.
• 12,944 individuals or 46% received care from Predoctoral Dental School programs, while 14,941 or 54% received care from Postdoctoral Dental Residency Programs.
• Of the total number of individuals reported receiving care, the largest number (19,117 or 69%) was served by programs in the Northeastern states. This was followed by programs in the Midwestern states (4,984 or 18%), and by programs in Southeastern states (3,724 or 13%).
• Slightly less than one half of all reported DRP patients (12,864 or 46%) received care in programs located in NY state, and most (92%) of these were cared for in Postdoctoral Education Programs.

Slide 10: Gender Distribution of Individuals Served

Image: Pie Chart

Data:
Males: 67%
Females: 32%
Transgender: <.01%
Unknown/Unreported: <.01%

• Overall, 18,797 or 67% of the individuals served were males while 9,001 or 32% were females.
• Programs in two states (CT and SC) reported that about half of their patients (55% and 41%, respectively) were females

Slide 11: Age Distribution of Individuals Served by the DRP Program

Image: Bar Chart

Data:
0 - 12 years of age: 3%
13 - 19 years of age: 2%
20 - 24 years of age: 5%
25 - 44 years of age: 53%
45+ years of age: 35%
Unknown/unreported: 1%

• Most individuals (53%) who received care were 25 - 44 years of age.
• Programs in AL and UT reported that seven in ten of the patients they served (70%) were in the 25-44 age group.
• Programs in CA, CT, IL, MI, OR and WA reported serving higher proportions of individuals over 45 years of age (52%, 49%, 48%, 57%, 51% and 53%, respectively).

Slide 12: States with Programs Serving the Highest Number of Children and Adolescents

Image: Bar Chart

Data:
South Carolina (N=85)
13 - 19 years 2.0%
0 - 12 years 24.0%

District of Columbia (N=1,151)
13 - 19 years 5.0%
0 - 12 years 11.0%

Maryland (N=601)
13 - 19 years 3.0%
0 - 12 years 2.0%

New York (N=12,864)
13 - 19 years 2.0%
0 - 12 years 4.0%

North Carolina (N=152)
13 - 19 years
0 - 12 years 5.0%

• Of all persons cared for, only 1253 or 4.5% were children and adolescents age 0-19 years
• Some programs focus on the care of pediatric and adolescent patients. Programs in DC, FL and NY reported a higher than average number (15.7%, 6.1%, 5.7%) of their total case load in these age groups.
• Providers in SC and DC have a substantial proportion of their total caseload as youth with children (0-12 yrs) making up the majority of these patients.

Slide 13: Race Distribution of Individuals Served

 Image: Pie Chart

Data:
White - 40%
Black - 43%
Asian - 1%
Native Hawaiian or other Pacific Islander - <.01%
American Indian or Alaska Native - <.01%
Multiple races - 8%
Unknown/Unreported race - 8

Slide 14: Race Distribution of Individuals Served

Image: Pie Chart

Data:
Hispanic - 30%
Non-Hispanic - 65%
Unknown - 5%

• In 2001, the Office of Management and Budget (OMB) redefined ethnicity as a demographic element separate from race, with the following categories - Hispanic, Non-Hispanic and Unknown Ethnicity.
• One in three (30%) of all patients served by the DRP are of Hispanic or Latino/a ethnicity.
• All patients (100%) in PR, and seven in ten (70%) in FL were of Hispanic ethnicity. NY and UT also cared for substantial proportions of people of Hispanic ethnicity (41% and 30%).
  

Slide 15: Populations Served

• Blacks/African-Americans and Whites each make up about four in ten (43%, and 40%) respectively of all patients served.
• Minority groups in general make up about one-half (52%) of the DRP patients, and most (82%) of these are Blacks/African-Americans.
  

Slide 16: Pregnant HIV+ Women Served

Image: Pie Chart

Data:
Dental Schools: 12.9%
Postdoctoral Programs: 87.1%

• A total of 224 pregnant women with HIV were cared for by DRP participating institutions.
• DRP institutions in NY and FL cared for 206 or 92% of these pregnant patients, with the majority of all the pregnant patients, 185 or 83%, cared for by programs in NY alone.
• The majority (87% or 195) of all pregnant patients were cared for by postdoctoral dental residency programs.

Slide 17: Number of Visits for Most Frequently Provided Oral Health Services*

Image: Bar Chart

Data:

• A total of 162,266 oral health care service visits were made to DRP institutions.
• A total of 68,908 or 45% of these visits were made to Predoctoral Dental programs, while 83,582 or 55% were made to Postdoctoral residency programs.
• Seven categories of procedures (Restorative, Diagnostic, Prosthodontic, Oral Surgery, Preventive, Periodontic & Oral Health education) account for 132,515 or 82% of the total service visits.
• Diagnostic and Restorative service visits are the most common.
  

*Since patients may receive treatment over multiple visits , the number of service visits exceeds the number of HIV+ patients.

Slide 18: Uses of DRP Funds

Image: Bar Chart

Data:

• A majority of applicants reported using DRP funds to support direct patient services, as well as student and patient education which are key DRP components.
  
• Most institutions reported using DRP funds for dental equipment and supplies, as well as for clinic staff salaries and training, both of which help strengthen the infrastructure essential for dental health service delivery.

Slide 19: Reimbursed vs. Non-ReimbursedOral Health Care

Image: Pie Chart

Data:
Partial Reimbursement: 57%
No Reimbursement: 42%
Unknown: 1%

• Slightly more than four in ten (42%) of the patients served by the DRPs had no other sources of reimbursement to cover the costs of their care.
• About seven-tenths (67%) of the $13.7 million in total costs of HIV care provided by DRPs was not reimbursed by any source other than DRP.
• DRP applicants in four states (FL, GA, MA & TX) reported the lowest reimbursement levels, far below the cost of care they provided.
  

Slide 20: Institutions’ Unreimbursed Costs and DRP Awards: 1997 - 2003

Image: Bar Chart

Data:

• Since FY97, DRP institutions have reported a total of $101.7 million in unreimbursed costs. Within that period a total of $59 million in DRP funds have been awarded to support applicants.
• Since 2001, the reimbursement level of DRP awards has been between 70 and 75 cents for every unreimbursed dollar reported.
• In 2003, 72% of the institutions’ reported unreimbursed costs was offset by DRP awards.

Slide 21: Source of Reimbursed Cost

Image: Bar Chart

Data:
Medicaid (Non-HMO) - 51%
Medicaid (HMO) - 19%
Unknown - 11%
Self-Pay - 10%
Private Insurance - 6%
Public Insurance - 4%
Medicare - 1%

• One half (51%) of all patients who had some reimbursed care had Non-HMO Medicaid.
• DRP programs in CT, MO and SC reported that over 80% of their reimbursements came from Non-HMO Medicaid.
• Programs in LA, PA, NC and PR reported that over 80% of their reimbursements came from Medicaid-HMO.
• TX and MI programs, on the other hand, reported that almost all of their reimbursements (100% and 71%, respectively) came from Self Pay.
  

Slide 22: Fiscal Characteristics

Image: Trend Chart

Data:

• Total non-reimbursed oral health care costs reported by all participating Dental Reimbursement Program applicants was $13,665,147.
  
  Pre-doctoral Dental School Programs reported approximately $5.3 million in non-reimbursed costs.
  
  Postdoctoral Dental Residency Programs reported approximately $8.3 million in non-reimbursed costs.
  
  
• Applicants in New York state reported the highest amount of non-reimbursed costs, about $6.5 million.
• The sum of reported non-reimbursed costs totaled more than $1 million in each of four states - NY, CA, FL, and MA.

Slide 23: Average Non-reimbursed Oral Health Care Cost, 1997-2003

Image: Trend Chart

Data:

1997 - $130,325
1998 - $150,872
1999 - $164,172
2000 - $194,893
2001 - $175,209
2002 - $198,769
2003 - $213,518

• Notably the number of DRP applicants has decreased by 38% since 1997, yet the average non-reimbursed cost per institution has continued to increase.
• Overall, the average non-reimbursed cost of oral health provided rose from $130,325 in 1997 to $213,518 in 2003.
• Since 1997, Postdoctoral Residency Programs have reported the highest proportion of non-reimbursed cost increases.
  

Slide 24: Training Characteristics:Curriculum Hours

Image: Bar Chart

Data:
Post-doc Residents
Required hours 20355
Elective hours 766

Dental students
Required hours 8980
Elective hours 1899

Dental hygiene students
Required hours 5508
Elective hours 742

• A total of 38,356 education curriculum hours (didactic and clinical) were dedicated by DRP institutions to HIV care issues.
• All but a few (99.8%) of these were Required hours as opposed to Elective. More than one-half of these hours (55%) was part of Postdoctoral residency curricula.

Slide 25: Training Characteristics:Formal Didactic Instruction in HIV Care

Image: Bar Chart

Data:
All Students & Providers - 1,2371
Pre-doc Residents - 9,204
Post-doc Residents - 1,992
Dental hygiene students - 990
Other Providers - 185

• A total of 12,371 out of the 14,095, (88%) students enrolled in DRP institutions received formal didactic instruction in HIV care.
• About seven in ten of these students (74% or 9,204) were Postdoctoral Dental residents.
• DRP applicants in three states (MI, MN, and MD) reported the largest numbers of Dental Hygiene students who received formal didactic instruction in HIV care (28%, 18% and 13%, respectively).
  

Slide 26: Training Characteristics:Providers Who Gained Clinical Experience in Providing HIV Services

Image: Bar Chart

N=6,869

Data:

Other Providers - 134
Dental Hygiene Students - 418
Postdoc Residents - 1,549
Dental Students - 4,768

• Of the 6,869 students and residents who gained clinical experience providing HIV care, about seven in ten (69.4%) were Predoctoral Dental students.
• DRP applicants in three states (AL, MN, LA) reported higher proportions of Postdoctoral residents who gained clinical experience (87%, 48% and 45%, respectively).

Slide 27: Training Characteristics:Hours of Clinical Care Provided

Image: Bar Chart

Data:
Predoc Dental students - 25,823
Postdoc residents - 48,631
D.h. students 15,484
Providers - 3,354

• Students and residents in DRP-supported programs reported spending a total of 93,292 hours providing clinical care for HIV+ patients.
• One-half of these hours (52% or 48,631) was provided by post-doctoral residents.
• Pre-doctoral Dental students reported providing a total of 25,823 hours of HIV-related clinical care.

Slide 28: Training Characteristics:Hours Spent in Providing Direct Clinical Care

Image: Bar Chart

Data:
Postdoctoral 330
Predoctoral 170
Dental Hygiene 98
Other non-student providers 2

• Programs were asked to estimate how many hours, on average their students and residents spent providing direct clinical care.
  
• DRP programs reported a student or resident average of 1,458 hours spent providing direct clinical care.
  
• Post-doctoral residents provided nearly twice as many hours of clinical care as Pre-doctoral students.
  

Slide 29: Other Ryan White CARE Act Funding

Data:

• About one in two (55%) Dental Reimbursement Programs reported that their parent institutions received funding from other CARE Act programs in 2003 (to support the provision of all HIV services, not necessarily oral health services).
• The reported total amount of other Ryan White CARE Act funds received by the parent institutions of DRP programs was $22,634,442. Parent institutions with Postdoctoral Residency programs (mostly hospitals and community-based organizations) received 80% of these funds.
  
  $8,903,795 from Title I
  $3,078,878 from Title II
  $6,426,743 from Title III
  $2,800,513 from Title IV
  $668,570 from Special Projects of National Significance (SPNS)
  $755,943 from AIDS Education and Training Centers (AETC) program