COMPONENTS OF PROFESSIONAL CARE
EXPENDITURES FOR ORAL HEALTH CARE
FINANCING AND REIMBURSEMENT
FACTORS AFFECTING THE CAPACITY TO MEET ORAL HEALTH NEEDS
TWENTY-FIRST CENTURY CHALLENGES: WHAT LIES AHEAD?
FINDINGS
REFERENCES
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Achieving optimal oral, dental, and craniofacial health requires a commitment to self-care and preventive behaviors as well as the receipt of appropriate professional care. Community-wide approaches to support oral health and the role of professional services are covered in Chapters 7 and 8, respectively. Although the services provided by dental practitioners are the first that come to mind when people consider the nation’s resources to address the diseases and disorders that affect the craniofacial complex, the dental component is augmented by two other components—medicine and public health. These three do not constitute a single system of care, but serve as individual components variously involved in the promotion of health and the provision of services to individuals and families, communities, and the population at large. The linkages and overlaps among the components mirror those between oral and general health described elsewhere in this report (e.g., Chapters 2, 3, 5, and 6), and may also play a role in the disparities noted in Chapter 4.
As has been noted in previous chapters, data regarding the contributions to oral health care made by the medical and public health components are not nearly as available as those that describe the contributions made by dental practitioners. Most of this care is provided by dentists in private practice. Expenditures for their services represented over 96 percent of the estimated $53.8 billion spent on dental care in 1998, or 4.7 percent of the $1.1 trillion spent on all health care in the United States that year (HCFA 2000b). Although they surely undercount the contributions of the medical and public health components, these expenditures indicate the burden that oral diseases and conditions place on the American people, as well as their willingness to invest in the prevention, treatment, and rehabilitation of oral conditions—a reflection of the value they place on oral health.
There have been notable achievements in oral health over the years, among them the dramatic and continuing reduction in the prevalence of dental caries in sizable population groups (see Chapter 4). This has led to an impressive decline in tooth loss, with the result that the majority of Americans can now expect to retain their natural teeth over their lifetimes. At the same time, all three components have participated in the revolutions in biomedical and behavioral sciences and technology that have deepened our understanding of the biological, environmental, behavioral, and genetic origins of many oral, dental, and craniofacial diseases. Americans today can benefit from oral health services that are among the best in the world. Moreover, as new and improved preventive, diagnostic, and treatment measures emerge (see Chapter 8), they create further opportunities for improving the nation’s oral health.
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COMPONENTS OF PROFESSIONAL CARE
The dental, medical, and public health contributions to oral health differ dramatically in their size, focus, financing, and resources. Following is a brief description of each component and their areas of overlap.
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The Dental Component
Comprehensive oral health care in America is largely supplied by a private dental care system composed of dentists, dental hygienists, dental assistants, laboratory technicians, and other professional staff in independent dental offices. The estimated numbers of active dental personnel are presented in Table 9.1. Of the 156,500 professionally active dentists in the United States in 1997, 91.7 percent were in private practice (ADA 1998a). Women constitute 14.4 percent of the total, and minorities 11.1 percent (ADA 1998a). Other professionals, who are educators, biomedical and behavioral science researchers, technicians, manufacturers of dental products, and administrators, complement this workforce.
In contrast to medicine, where only 40 percent of physicians were in primary care practices in 1990, approximately 80 percent of dentists are general practitioners (ADA 1998a). The remainder qualify as specialists in one or more of the nine disciplines formally recognized by the American Dental Association: orthodontics, oral and maxillofacial surgery, oral and maxillofacial radiology, periodontics, pediatric dentistry, endodontics, prosthodontics, dental public health, and oral and maxillofacial pathology. More than half of these specialists are orthodontists or oral surgeons (ADA 1998a). A small number of dental practitioners focus on special interest areas such as anesthesiology or oral medicine. There has been little change in the approximately 4 to 1 ratio of general dentists to specialists in the past 10 years.
New technologies and changing patterns of disease are broadening the scope of dental practice. The average general practitioner and staff now engage in more preventive services than in years past (ADA 1990). A reduction in the number of amalgam and resin restorations per patient per year from 1980 to 1995 has also been noted (Eklund et al. 1997). Although dentists perform fewer extractions and restorations, preserving the teeth of an aging population has increased the need for crowns and periodontal treatment.
Since oral health is an integral part of total health, most dentists provide primary care services to their patients. In addition to educating patients on oral health care, dentists and their staff may counsel patients on tobacco and other substance use and cessation, nutrition, and dietary practices. In addition, information that dentists obtain from a patient’s history and from screening and diagnostic tests may suggest the presence of systemic disease, warranting a referral of the patient to other health care professionals.
Dental services are provided in a practice model that is different from that used by the medical profession. Most private dental practices consist of one dentist (68.7 percent) or two dentists (19.6 percent). The remaining practices (11.7 percent) are group practices of three or more dentists who share expenses and revenues. This distribution of dentists by practice size, along with the number of hours worked per week, has remained remarkably constant over the years (ADA 1998a). The size, number, and location of dental practices are important determinants of availability of care and accessibility to services, as well as of the unit cost of care. Figure 9.1 shows the association between the availability of dentists and state mean per capita income (Burt and Eklund 1999). Dental care is also provided in dental schools and public health clinics, hospitals, nursing homes, and other institutional settings. These are sometimes the principal source of oral health care for communities and special population groups with limited access to health care.
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The Medical Component
In the context of oral, dental, and craniofacial health care, the medical component includes dentists, physicians, nurses, and allied health professionals whose services are provided through hospitals, nursing homes, ambulatory care facilities, and health professional offices. Data on the nature and extent of such oral health services, as well as on the number of nondental professionals who supply them, are limited. For some conditions—particularly developmental anomalies, injuries, infectious diseases, pain syndromes, and oral and pharyngeal cancers—the medical component provides comprehensive care, often working in tandem with dental specialists and general practitioners. For example, physicians and oral and maxillofacial surgeons may plan treatments together and operate on individuals born with cleft lip/palate to repair the clefts as the children age. Orthodontists, pediatric dentists, prosthodontists, and other dental specialists, speech and hearing therapists, plastic surgeons, neurologists, radiologists, nutritionists, psychologists, other health professionals, and social workers are also part of the craniofacial team.
Collaboration and coordination between physicians and dentists are needed to provide integrated medical and oral health care for cardiac patients and those undergoing chemo- and radiation therapy or implant and organ transplant procedures. Nondental health care personnel in long-term and geriatric care facilities may be the principal sources of oral health care given to residents.
Although most hospitals have dental personnel on staff to handle emergency situations, emergency room physicians and other hospital personnel are often called on to initiate treatment of acute oral-facial injury or pain of dental origin, with referrals to dentists for follow-up. Also, patients with chronic oral-facial pain conditions are sometimes treated by family practice, internal medicine, or neurology physicians, sometimes with referral to dental or other medical specialists.
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The Public Health Component
Federal, state, and local government agencies support a range of oral health activities and programs benefiting individuals and communities. This component includes health professionals and administrators who participate in publicly funded care delivery programs, research, disease surveillance, policy development, and implementation of programs aimed at preventing disease and promoting health.
Federal agencies under the jurisdiction of the U.S. Department of Health and Human Services (USDHHS) and the U.S. Departments of Defense, Veterans Affairs, Agriculture, Education, Transportation, and Justice, among others, serve public health needs in diverse ways. These agencies may include units or programs specifically dedicated to oral health, as well as components that collect, organize, or make available information or services related to oral health as part of general health programs. For example, the National Institutes of Health (NIH) is the primary federal agency supporting biomedical and behavioral research and research training. Assurance of the safety of foods, cosmetics, drugs, and devices is provided through the regulatory authorities of the Food and Drug Administration (FDA). The Centers for Disease Control and Prevention (CDC) focuses on state-based programs for monitoring and preventing disease and, through the National Center for Health Statistics, orchestrates the collection of nationally representative health information and population data. The Agency for Healthcare Research and Quality (AHRQ) uses evidence-based practice centers to evaluate literature relevant to the management of diseases and conditions, conducts national expenditure and care utilization surveys, and supports research directed at understanding health care systems. The Medicaid, Medicare, and newly enacted State Children’s Health Insurance Program (SCHIP) programs are directed by the Health Care Financing Administration (HCFA), which funds a variety of care services prescribed by law or regulation.
Several federal agencies provide direct services to specific, often disadvantaged populations or to military personnel and their dependents. The U.S. Departments of Defense, Transportation, and Veterans Affairs, the U.S. Department of Justice’s Bureau of Prisons, and the USDHHS’s Indian Health Service (IHS) and Health Resources and Services Administration (HRSA) provide oral health care directly to selected populations. Oral health education also is provided through the U.S. Department of Agriculture’s Women, Infants and Children WIC program. In addition, HRSA provides funds for health professional education and administers the Ryan White Comprehensive AIDS Resources Emergency Act. States, counties, and cities also support dental programs for disadvantaged populations under federally mandated and funded Maternal and Children’s Health Programs or as part of Medicaid or the State Children’s Health Insurance Program. They may also provide direct support through tax revenues. The Head Start programs of the Administration for Children and Families (ACF) provide health education services and in some cases may pay for oral care services for enrolled low-income children 5 years old and younger.
Many organizations have activities that could be used to promote oral health, given appropriate collaboration. In this regard, studies of the federal oral health infrastructure have emphasized the need for federal programs to maximize partnerships within and beyond the federal government. A 1989 report recommended increasing the capacity of USDHHS agencies to direct dental expertise to programs that can affect oral health or dental care, and establishing a mechanism for coordinating programs and sharing expertise across agencies. The report recommended that a national advisory committee be established to assess opportunities, accomplishments, and needs (USDHHS 1989). A 1994 report determined that the collection and analysis of data related to oral health and dental care had not been maintained at a level consistent with analogous general health and health care data used for public program planning, development, and evaluation (SysteMetrics, Inc. 1994). Despite some progress, many of the recommendations of these reports have not been implemented; thus many of the deficiencies noted have not been fully addressed.
Table 9.2 presents the scope of services and activities supported by USDHHS agencies. It identifies each agency’s principal activities in terms of the “essential public health services” conducted at federal, state, and local levels. The approximate fiscal year 2000 funding levels provide a sense of how the proportion of oral health programs varies across agencies.
Local public health departments, community health centers, nongovernmental organizations, dental schools, and volunteer groups are examples of entities that implement oral health programs in association with government agencies and the private sector. These collaborations are enhanced by state oral health programs as they direct and integrate public health services. Not every state health agency has an oral health program, however. Further, not all state oral health programs have sufficient resources to address oral health needs. For example, although 31 states and five territories currently have full-time state dental directors, in 20 states (including the District of Columbia), the state dental director positions are part time or vacant. Additionally, 21 states, with 67 million people, have two or fewer full-time equivalents staffing a state oral health program. In 25 states, fewer than 10 percent of the counties have oral health programs in their local health departments (ASTDD 1999).
The Association of State and Territorial Dental Directors (ASTDD) recently assessed the resources needed to achieve the objectives in Healthy People 2010. The study focused on the gaps in infrastructure and capacity of state oral health programs. Infrastructure consists of the systems, people, relationships, and resources that would enable state oral health programs to perform public health functions. Capacity describes the expertise and competence needed to enable the implementation of strategies. Box 7.3 describes the essential public health services for oral health in the areas of assessment, policy development, and assurance as noted in ASTDD’s Guidelines for State and Territorial Oral Health Programs. In particular, states have high needs for oral health surveillance systems and staff with epidemiologic and other public health expertise (ASTDD 2000). Similar gaps occur in many local public health departments that lack adequate oral health programs or appropriately trained personnel (USDHHS 2000).
Public health agencies at all levels have identified disparities in oral health and access to care, in terms of both population subgroups and geographical areas. In 1998, there were 1,036 Dental Health Professional Shortage Areas (HPSAs), which required 3,984 dentists. Of 686 consolidated Community Health Center grantees, 385 (or 56 percent) provide dental services (J. Anderson, HRSA, personal communication, 1999).
Community Health Centers provide preventive and basic dental care to 1.2 million patients nationwide (HRSA 1998). Health Centers are located in medically underserved urban and rural areas and target low-income, migrant, homeless, and other disadvantaged populations. Individuals pay for dental services on a sliding fee scale adjusted by their ability to pay. Health Centers are a primary source of care for 2.84 million Medicaid-eligible individuals, who make up 33 percent of Health Center clients. An additional 3.55 million uninsured patients represent 41 percent of their clients (HRSA 1998). Health Centers that provide oral health care include it as part of an integrated primary care system. In addition, federal programs such as the National Health Service Corps offer scholarships and loan repayment opportunities to encourage newly licensed dentists to locate in underserved areas.
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Areas of Overlap
The various components of oral health care work together in diagnosis, prevention, and treatment services. As mentioned above, dental and medical specialists work on teams treating patients with craniofacial birth defects. Oncologists, radiologists, otolaryngologists, plastic surgeons, and surgeons specializing in head and neck surgery similarly may partner with oral and maxillofacial surgeons and prosthodontists in treating oral and pharyngeal cancers and other tumors of the oral cavity and pharynx. Dentists also are active members of general oncology teams. They participate in the examination of patients about to undergo chemotherapy, radiation, or bone marrow transplantation, for example, to ensure that proven preventive measures are taken before treatment to minimize the effects of the therapy on the oral mucosa, salivary glands, and dentition.
Private medical and public health professionals often collaborate in implementing immunization programs and other preventive strategies to reduce a specific disease or to change risk behaviors. Similarly, dental personnel in the private and public sectors cooperate in the implementation of mouthguard programs for sports injury prevention, statewide programs to apply sealants to the teeth of low-income children, and the promotion of oral health self-care behaviors. Private practitioners can deliver care that is paid for by public programs or can work as contractors to Migrant and Community Health Centers and local health departments, among others. Finally, all three components can work together to promote programs that address cross-cutting issues such as tobacco cessation and the prevention and control of HIV disease, oral and pharyngeal cancers, and early childhood caries.
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EXPENDITURES FOR ORAL HEALTH CARE
The $1.1 trillion spent in the United States on health care services in 1998 includes the cost of hospital care, physician and dental services, home health care, nursing home care, prescription drugs, medical equipment, private health insurance, public health activities, and research and represents an increase of 5.6 percent from 1997 (HCFA 2000b). Analysts project that this amount will double by 2007 to total more than $2.1 trillion (HCFA 2000a).
Expenditures for dental services in the United States in 1998 were $53.8 billion, a 5.3 percent increase from 1997 and 4.7 percent of the total spent on health care that year (Table 9.3 and Figure 9.2). This figure is an undercount, however, because it represents only those costs associated with care delivered by dentists in practice settings. A generation earlier, in 1960, $2 billion was spent on dental care, which represented 7.3 percent of that year’s total health care expenditures. During the 1970s, dental expenditures grew at approximately the same rate as personal health care expenditures, with both exceeding the growth of the economy overall. But starting in 1978, dental expenditures began to flatten and, until 1994, increased more slowly than expenditures for personal health care. Since 1994, dental expenditures have increased at a higher rate than personal health care expenditures (Levit et al. 1998).
Real per capita dental care expenditures (1995 dollars) are currently at about the level they were in the early 1980s, and in some years have declined (Figure 9.3) (ADA 1997b, Beazoglou et al. 1993, Beazoglou 1998). The American Dental Association estimated that $174.12 was spent per capita in 1995 for dental services (ADA 1997b); HCFA estimated the same year’s per capita consumer expenditures for dental services at $164 (U.S. Bureau of the Census 1998).
The annual percentage change in fees for medical, physician, and dental services as measured by the Consumer Price Index (CPI) has generally exceeded that for the index as a whole (U.S. Bureau of Labor Statistics 1999) (Table 9.4 and Figure 9.4). Percentage changes in the dental CPI have generally followed those for other medical services; since 1983, however, prices for dental services have increased at a rate faster than those for physician and all medical services. These trends signal different market forces for dental care services as compared to other health services.
In addition to dental care expenditures for services provided by dentists in practice settings, the full cost of oral health care in the United States must take into consideration the breadth of oral, dental, and craniofacial conditions for which services are provided in hospital and other institutional settings, often by nondentists. For example, the Healthcare Cost and Utilization Project (2000) estimated inpatient hospital charges for diseases of the mouth and disorders of the teeth and jaw to be $451 million in 1996. Estimates for the management of severe early childhood caries range from $1,500 to $2,000, depending on whether hospitalization is necessary (Griffin et al. 2000, Kanellis et al. 2000). In Iowa the average cost of treating this condition in a hospital operating room was estimated to be $2,578 (Damiano et al. 1996). In California, the lifetime cost per case for cleft lip/palate repair is estimated at $101,000 (Waitzman et al. 1996).
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FINANCING AND REIMBURSEMENT
Dental care is financed principally through private sources, either as out-of-pocket payments made directly to the dentist or through employment-based dental insurance benefits. Since 1960, these two sources have financed over 93 percent of all dental expenditures (Figure 9.5). Table 9.5 shows the change in contributions for dental expenditures from 1970 to 1996. The proportion of dental expenditures that private dental insurance covers has increased over the past two decades. Dental insurance now contributes about 48 percent of dental expenditures, as compared to 50.1 percent contributed by medical insurance for physician services. In contrast, the percentage of out-of-pocket payments for dental services is over 3 times that for physician services (Figure 9.6). Sharp differences are also evident in terms of federal, state, and local government contributions to the cost of dental care as compared to physician services. Only 4.0 percent of dental care costs, or $2.3 billion in 1998, is financed publicly (largely through federal-state Medicaid programs), compared to 32.2 percent for medical care. Few hospital dental services are reimbursed by Medicare, and state Medicaid programs may provide low reimbursement for dental services. In contrast, public sources pay a large part of hospital costs for medical care.
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Insurance
Insurance is a major determinant of dental utilization: 70.4 percent of individuals with private dental insurance reported seeing a dentist in the past year, compared to 50.8 percent of those without dental insurance (Bloom et al. 1992). Private dental care benefits are available to most full-time employees (59 percent) in medium-sized and large businesses. Fewer small businesses offer dental benefits. For the 22.6 million employees with employer-provided dental benefits, dental care may be offered as part of a comprehensive medical and dental plan or as a separate plan. Firms often offer employees a choice of medical plans as well as a separate dental plan that can accompany any medical plan. For employees with employer-provided dental benefits, 81 percent received care through fee-for-service plans, 11 percent from preferred provider organizations, and 8 percent from health maintenance organizations (HMOs) in 1998 (EBRI 1998).
Most participants in employer dental plans receive benefits through a fee-for-service plan, which reimburses patients or providers after services are received. Such plans are commonly obtained through a commercial insurer, or are self-insured (the firm sets aside funds to meet expected charges), or are a combination of the two. Among self-insured plans is a type of dental plan called direct reimbursement, which enables patients to pay the dentist directly based on what they have been charged. The patients are reimbursed by the plan based on their expenditures, up to a predetermined limit for total expenditures, but not according to the type of service they receive.
Dental insurance plans that reimburse dentists by type of service performed typically cover technical procedures but not counseling services, treatment planning, or disease management. Diagnostic and preventive care usually includes dental examinations, prophylaxes, sealants, and radiographs. Restorative procedures may be limited to fillings, but may include crowns. Other services that may be covered include periodontal care, endodontic care, prosthetics, and oral surgery. Orthodontic care is covered less often by dental plans than are other procedures. In addition, most plans limit orthodontic coverage to dependent children and set maximum allowable payments. Dental implants, cosmetic procedures, and some preexisting conditions typically are not covered.
Dental insurance plans are similar to medical plans in defining the terms of payment on a fee-for-service basis. Typically, they may pay a percentage of the fee; they may pay up to a specified dollar amount using a table of allowances; they may require the patient to pay initial costs up to a fixed amount (a deductible); or they may pay a varying percentage of dental charges, based on a patient’s past use of dental services. In all cases, the patient pays the difference. Copayments are a larger percentage of the total cost of dental care than is the case for medical care.
Dental coverage varies by race/ethnicity, income, and educational levels. Whites (41.8 percent), people with 13 years or more of education (51.4 percent), and families with annual incomes of $35,000 or more (60.8 percent) have the highest percentage of insurance coverage in their demographic categories (Figure 9.7). Hispanic individuals have the lowest percentage of coverage (29.7 percent), followed by blacks (32.4 percent), a pattern seen in medical insurance as well. Because private dental insurance is typically an employment-related benefit, some individuals lose their dental coverage when they retire. As a consequence, people 65 and older reported the lowest levels of coverage (NCHS 1992).
Although over 14 percent of children under 18 have no form of private or public medical insurance, more than twice that many, 23 million children, have no dental insurance (Vargas et al. 2000). Over 15 percent of persons 18 and older have no form of medical insurance, but 3 times as many, over 85 million persons, have no form of dental insurance (NCHS 2000).
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The Changing Market
Increasingly, private dental insurance plans are entering into contractual agreements with dentists. The purpose of these agreements is to shift some or all of the financial risk to the clinician, the beneficiary, or both. These alternative reimbursement systems have been labeled “managed dental care.” As defined by the Physician Payment Review Commission (1997), managed care is “any system of health services payment or delivery arrangements where the health plan attempts to control or coordinate use of health services by its enrolled members in order to contain health expenditures, improve quality, or both.”
In dentistry the primary alternative reimbursement systems in place are the dental health maintenance organization, dental preferred provider organization (PPO), and dental referral network. Between 1995 and 1996, dental HMO enrollment grew 17.7 percent; it grew another 8.6 percent between 1996 and 1997, for a total enrollment of approximately 26.5 million people. Dental PPO enrollment grew 30.9 percent in 1996 and 32.6 percent in 1997 to a total of about 24.5 million people (Table 9.6). Dental indemnity increased by 10.1 percent in 1996 and 2.6 percent in 1997 to about 90.6 million persons (NADP 1998). By comparison, the Health Care Financing Administration reported an increased shift of employers and employees from indemnity to managed care health plans in the past several years. According to HCFA, 86 percent of all insured workers were covered by managed care health plans in 1998, an increase of 54 percent over 1993 (HCFA 2000b).
The rapid changes in the health care environment have emphasized the development of performance measures that can be used by both public and private purchasers of care, consumers, and health care professionals. Specifically, health care quality oversight has focused on the collection and use of data that provide the basis for assessing and monitoring care delivery performance. These performance or outcome measures require development and testing to determine their reliability and validity, and depend on enhanced data collection and information systems for their application. An example of performance measures is the Health Plan Employer Data and Information Set (HEDIS), a set of standardized measures developed by the National Committee for Quality Assurance. Recently, pediatric oral health measures have been reviewed and additional measures proposed for HEDIS consideration (Crall et al. 1999). A framework for the development of outcome measures for oral health care has been proposed along four dimensions: biologic, clinical, psychosocial, and economic. This schema is designed for potential use by patients, health care providers, purchasers of care, and the public (Bader and Ismail 1999). Efforts are needed to proceed with the development and testing of reliable and valid outcome measures in all four dimensions for oral health care and their incorporation into practice and programs.
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Federal and State Programs
Medicaid
The Medicaid program, established as Title XIX of the Social Security Amendments of 1965, was designed to provide health care for all indigent and medically indigent persons, with funding shared between federal and state governments. Although states differ in eligibility rules and expenditures for services provided, amendments to the Medicaid program instituted in 1968 required all states to include dental care for individuals under 21 years of age as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service. In addition, the Omnibus Budget Reconciliation Act of 1989 required the provision of all medically needed dental services for EPSDT beneficiaries beyond what is covered under the state’s Medicaid plan. Medicaid funds dental care for low-income individuals and persons with disabilities at usual and customary fees, or the Medicaid fee schedule rate, whichever is lower. Although some states have increased their medical reimbursement to 80 percent of usual and customary fees, the norm is 47 percent (Colby 1994).
In 1998, total governmental outlays for dental services were $2.3 billion ($1.3 billion federal, $1.0 billion state and local). Of this total, $2.0 billion represented dental Medicaid expenditures, which is approximately 1.25 percent of the $159.6 billion designated for all Medicaid personal health care expenditures, a proportion that is much lower than it was in the early years of the Medicaid program (HCFA 2000b). Some states have tightened their eligibility requirements and have reduced the range of covered dental services for adults. States have not been able to meet the mandatory components of the EPSDT dental program, partly because of low levels of reimbursement to providers and difficulties regarding access to care for eligible enrollees.
Eligibility for Medicaid, as with any form of insurance coverage, does not ensure receipt of adequate dental care. A 1996 report by the USDHHS Inspector General estimated that 80.3 percent of eligible infants, children, and youth up to 20 years of age, for whom disease levels are known to be high (see Chapter 4), did not receive preventive dental services (USDHHS 1996). The report stated that the reasons were complex and included the following factors: few dentists see Medicaid patients, Medicaid families give dental services low priority, and the youngest patients are the least likely to obtain care.
The State Children’s Health Insurance Program
Legislation passed by Congress in 1997 created the State Children’s Health Insurance Program, which provides billions of dollars to states (supplemented by required state contributions) to extend coverage for health care to uninsured children. For a child to be eligible, family income may be as high as twice the federal poverty level, exceeding eligibility for Medicaid. The states must cover immunizations and well-child care within specified program requirements, but are otherwise free to decide how the money is spent. By midsummer 1999, only 1.3 million of the 10 million uninsured children had been enrolled in SCHIP, with some states using the funds to expand Medicaid coverage and others designing new programs that may or may not include dental care (see Chapter 10 for more details).
Medicare
Dental services covered under the Medicare program are limited. Unlike Medicaid, Medicare (Title XVIII of the Social Security Amendments of 1965) is financed totally by the federal government; it was originally designed to provide physician and hospital services for all persons 65 and older, rich and poor alike. Medicare is split into hospital insurance (Part A) and physicians’ services (Part B), the latter being a voluntary supplemental insurance program paid for by the individual.
Medicare was not designed to insure routine dental care. Rather, as an exception to the statutory exclusion from Medicare of dental services, it covers dental services needed by hospitalized patients with specific conditions. These include dental services in connection with jaw fractures or with preparation of patients for radiation in cases of oral and pharyngeal cancers or as part of a comprehensive workup prior to renal transplant surgery (Table 9.7). Total Medicare payments for dental services in 1998 were $0.1 billion (HCFA 2000b).
Recently, the Institute of Medicine (IOM) was asked to study the short- and long-term benefits and costs to the Medicare program of extending coverage to include “medically necessary dental care” to beneficiaries for a limited number of conditions. In the Medicare program, the term “medically necessary dental services” is used narrowly to mean care that occurs as the direct result of an underlying medical condition or its treatment or that has a direct effect on such a condition. Under this definition, care for serious periodontal disease would not be “medically necessary” unless, for example, it threatened the health of someone with leukemia or was caused by the disease or its treatment (and could otherwise be health threatening if untreated). The IOM report noted that such a restrictive definition may suggest that “periodontal or other tooth-related infections are somehow different from infections elsewhere” and “imply that the mouth can be isolated from the rest of the body, notions neither scientifically based nor constructive for individual or public health.”
The IOM committee concluded that it is reasonable for Medicare to cover both tooth-preserving care and extractions for patients undergoing radiation for oral and pharyngeal cancers, and a dental examination, cleaning of teeth, and treatment of acute infections of the teeth or gingiva for a leukemia patient prior to chemotherapy. The report suggested that further study would enable recommendations to be made—on a condition-by-condition basis—for coverage of effective dental services needed in conjunction with surgery, chemotherapy, and radiation for other conditions (Field et al. 1999).
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FACTORS AFFECTING THE CAPACITY TO MEET ORAL HEALTH NEEDS
The nation’s capacity to provide care that is accessible and acceptable to address the oral health needs and wants of Americans in the next century is challenged by numerous factors. Among them are concerns about a declining dentist-to-population ratio, an inequitable distribution of oral health care providers, a low number of underrepresented minorities applying to dental schools, the effects of the cost of dental education and graduation debt on decisions to pursue a career in dentistry, the type and location of practice upon graduation, current and expected shortages in personnel for dental school faculties and oral health research, and an evolving curriculum with an ever-expanding knowledge base.
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Numbers of Dental Personnel
The ratio of dentists to the total population is declining: in 1996, there were approximately 58.4 professionally active dentists per 100,000 people in the United States, down from 59.1 in 1990. The current ratio equates to one dentist for every 1,700 people (HRSA 1999). The dentist-to-population ratio is a very crude measure of dental care capacity, because it does not consider dentist productivity (affected by hours worked, use of auxiliary personnel, and mix of services provided) or location of practices relative to underserved populations; there is no agreement on the number that is optimal. Nevertheless, this ratio does indicate trends. By 2020 the dentist-to-population ratio is expected to drop to 53.7 per 100,000 (Figure 9.8). Moreover, it appears that the absolute number of active dentists will decline after 2000. In part, this drop reflects the retirement of older dentists (estimated to range from 2,500 to over 4,300 per year between 1996 and 2021 (HRSA 1999) with insufficient numbers of new graduates (estimated at about 4,000 per year) replacing them (ADA 1999). In comparison, the ratio of active physicians to population has been increasing; it was 251.6 per 100,000 in 1997, up from 226.1 in 1990 (HRSA 1999). The trend in the reduction of the dentist-to-population ratio and the absolute number of dentists implies a shortage of dentists in the future. This trend may, however, be offset by innovation in dental practice. However, if the impact of future technology changes is similar to that produced by changes over the past 20 to 30 years, it will not substantially affect the projections.
The entering supply of dentists and dental hygienists depends on the number of graduates from dental and dental hygiene schools. The number of applicants to dental schools almost doubled between 1989 and 1997. However, the number of applicants declined by 4 percent in 1998, with further declines of 8 to 10 percent expected for 1999 and 2000. Based on the sharp decline that has occurred in the number of individuals taking the Dental Admissions Test, similar declines may continue into the early 2000s. During the 1989-97 time period, dental school first-year enrollment increased only about 9 percent. Little further growth in enrollment is anticipated because the current infrastructure in dental education has limited ability to expand, coupled with the declines occurring in dental school applicants. Along with concerns about a possible shortage of dentists, there is concern that the pool of qualified applicants may not be sufficient to supply a dental workforce that meets the needs of society, as well as the needs of dental education and research.
In contrast, the number of dental hygiene programs and students has increased almost 18 percent since 1990. The number of first-year dental hygiene students currently stands at 6,000, more than recovering from the 15 percent decline that occurred in these programs during the late 1970s through the mid-1980s. The last 4 years has seen a steady 11 percent growth in dental hygiene positions.
The numbers of dentists and sites of health profession education programs have been influenced by government policies and social factors. During the late 1950s an emerging shortage of health care providers (including dentists) was expected arising from the “baby boom” that began in the late 1940s. Beginning in the early 1960s, the federal government supported an expansion in the number of medical and dental schools and in class sizes. By the mid-1970s, the number of dental schools had grown from 47 to 60. First-year enrollments grew from 3,612 to 6,301. By the mid-1970s, a possible oversupply of physicians and dentists became a concern. Government support for all health profession education was substantially reduced. Through the 1980s, dental schools reduced their enrollment by 37 percent. By 1993, six dental schools, all affiliated with private universities, had closed.
Following the growth in dental school enrollments that has occurred since 1989, the 1998-99 first-year enrollment stood at 4,268 in 55 dental schools located in 33 states, the Commonwealth of Puerto Rico, and the District of Columbia. One more dental school (at Northwestern University) is scheduled to close in 2001. One is scheduled to open in 2001, at the University of Nevada at Las Vegas (ADA 1996). Total dental school enrollment in 1998-99 was 17,033 students, down from a peak of 22,842 in 1980-81.
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Sex and Racial/Ethnic Composition of Dental Personnel
The number and percentage of women in the dental and medical professions have continued to increase. Thirty years ago, women represented 1.3 percent of first-year enrollment in dental schools. By 1988, that proportion had risen to 35.7 percent, a level that has been relatively constant over the past 10 years. Recent trends indicate that the proportion of women in dentistry will continue to increase: by 2000, more than 26,000 women will be active practitioners; this is almost twice the number in 1990 (HRSA 1993, 1999). However, data from 1990 show that the proportion of dentists who were women (9.5 percent) was smaller than the proportion of female physicians (17.0 percent), female pharmacists (28.9 percent), and female optometrists (14.6 percent). The percentage change in the numbers of first professional degrees conferred to women by health field of study and race/ethnicity from 1981 through 1990 shows that although dentistry is second lowest (next to allopathic medicine), the percentage changes for Hispanic women and American Indian/Alaska Native (AIAN) women in dentistry were among the highest (46.7 percent and 500.0 percent, respectively), even though the actual numbers were low (HRSA 1993).
The participation of racial and ethnic minorities in dentistry does not mirror the dramatic increase in the entrance of women into the profession in the course of a single generation. The demographic profile of the U.S. population is changing rapidly, and is likely to continue to do so, with continued increases in racial and ethnic minority groups in comparison to whites. However, these trends and projections are not reflected in the dental or medical workforce.
The overall percentage of minority students has increased significantly, to the point that, in 1998, a little over 34 percent of the first-year students were members of a minority group. This overall percentage is up from 13 percent in 1980. However, the primary increase has come among Asian/Pacific Islander students, increasing from about 5 percent of enrollment in 1980 to almost 25 percent in 1998. At the same time, the proportion of black/African American, Hispanic/Latino, and American Indian students, together, has shown only a small percentage point increase since 1980, from about 7.5 percent to nearly 10 percent. The percentage of first-year enrollment in 1998 for black/African American students was 4.4 percent. It was 4.9 percent for Hispanic/Latino students and 0.4 percent for American Indians. These percentages for black/African American, Hispanic/Latino, and American Indian students are far less than their percentages in the U.S. population. In addition, a specific look at black dental school graduates during the 1980s and 1990s showed that although the number of black female graduates had increased, the increase was insufficient to offset the decline in black male graduates (HRSA 1993).
In 1996, African Americans made up 12.0 percent of the general population, but only 2.2 percent of active dentists (Brown and Lazar 1999). Similarly underrepresented were Hispanics, who accounted for 10.7 percent of the population, but only 2.8 percent of active dentists. The Hispanic population is the fastest-growing segment of the population and by 2002 will exceed the number of blacks (U.S. Bureau of the Census 2000). American Indians, 0.7 percent of the population, represented only 0.2 percent of active dentists. Table 9.8 shows the 1996 dentist-to-population ratios by race/ethnicity of the dentist.
As has been shown in Chapter 4 and elsewhere in this report, oral health problems disproportionately affect disadvantaged populations among underrepresented minority groups. This disparity will not be ameliorated through technology improvements or increases in clinical productivity. Moreover, recent data show that underrepresented racial and ethnic minority dentists are more likely to provide care to minority populations. In 1996, black dentists reported that 61.8 percent of their patients were black, and Hispanic dentists reported that Hispanic patients made up 45.4 percent of their practice; 76.6 percent of white dentists’ patients were white (Brown and Lazar 1999). A recent study of the role of black and Hispanic physicians in the provision of care for underserved populations demonstrated that these physicians practiced in communities with a higher percentage of their racial or ethnic group (Komaromy et al. 1996). Also, black physicians saw more Medicaid patients, and Hispanic physicians more uninsured patients, than other physicians. If this pattern of treatment of Medicaid patients and the uninsured is similar for dentists, the underrepresentation of minority dentists may also contribute to the unmet needs of minority patients. This issue warrants further research.
Regarding the importance of reaching parity in the dental profession, the American Association of Dental Schools comments, “The production of underrepresented minority [URM] dentists is totally out of synch with projected U.S. demographics. The U.S. population is expected to increase by 60 percent, reaching 394 million by 2050. At that time, nearly half (48 percent) of the population will be constituted from racial and ethnic minority groups. Strategic measures are needed to increase the number of URM dental graduates that will improve access to care for minorities throughout the nation” (AADS 1999).
Recruitment and retention of underrepresented minorities and women into the health professions will continue to be a challenge in the coming years. Activities such as enrichment programs in science and mathematics for grades K-12 and precollege are designed to increase the interest and capacity of all students, including women and underrepresented minorities, in health professions and science careers. These efforts will require careful design, implementation, and evaluation.
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Student Indebtedness and Its Effects
The American Association of Dental Schools reports that in 1998 graduates of dental schools had incurred, on average, over $84,000 in educational debt (G. Luke, AADS, personal communication, 1999). Average debt ranged from $71,000 for graduates of public schools to $98,000 for private/state-related schools and $108,000 for private schools. This was over 14 percent more than the educational debt of graduating medical students. Specialty education may result in additional debt. Setting up an office involves additional costs. In the end the burden of debts to be repaid is a driving force in decision making for many new graduates regarding career direction and practice site.
Fewer dentists establish practices in low-income communities. The National Health Service Corps (NHSC) was created in 1970 as a program of the U.S. Public Health Service to provide financial assistance to health professionals who agree to locate in a Health Professional Shortage Area (HPSA). The NHSC offers programs for both students and clinicians, including scholarships, loan repayment programs, and rotations in Community Health Centers. Currently, there are approximately 2,526 clinicians, including 306 dental care providers, delivering care to more than 4.6 million people through these programs. Only about 6 percent of the dental need is currently being met in the approved 1,198 dental HPSAs with a population of 25.9 million. It is estimated that an additional 4,873 dental care providers are needed to meet the current demand. In fiscal year (FY) 1999 the NHSC provided 139 new and continuing dental loan repayment awards, valued at $9 million. In FY 1998, there were 308 dental NHSC scholars, a 40 percent increase since 1994. Outreach and program development are critical to foster growth and create opportunities for placing dentists in underserved areas, where the needs are great.
In addition to the NHSC, the Indian Health Service operates a loan repayment program to identify health professionals who will practice full-time at an IHS facility or approved tribally managed site in exchange for repayment of their eligible health professions educational loans. Funding for this program has remained level for the past 8 years, in spite of the fact that student debt has nearly doubled during that time.
Primary care dental residency programs supported by Health Professions Training Funds also play a role in meeting the oral health care needs of the nation. An evaluation performed for the USDHHS found that 87 percent of General Dentistry trainees remain in primary care practice and over 30 percent of General Dentistry program graduates receiving federal support over the last 4 years entered practice in underserved communities.
The issue of indebtedness not only is an important consideration for the graduate in deciding where to practice, but also has become an obstacle to college students contemplating a career in dentistry and other health professions. Moreover, it can affect the choices graduates make about whether they will pursue careers in academia or research. The National Institutes of Health created three loan repayment programs to attract health care professionals to research in its facilities. In addition, innovative loan repayment incentives, such as awarding “extramural” loan repayment to researchers working in dental education institutes, have been proposed to overcome the current critical shortage of dental faculty/researchers.
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Personnel Needs for Faculty and Clinical Research
The education and training of dentists and allied dental health personnel are essential to the country’s capacity to meet its oral health needs. Dental education institutions and their allied academic health centers play a critical role in providing the infrastructure for oral, dental, and craniofacial research and continuing education for dental professionals. A task force report on the future of dental school faculty shows that the number of faculty vacancies in the clinical sciences has more than doubled in recent years, rising from 139 in 1992-93 to more than 300 in 1999 (AADS 1999). The task force projects that retirements will rapidly increase in the coming decade given the average age of the faculty (47 percent of all faculty members are aged 50 and older, and 19 percent are 61 and older). Kennedy (1990) estimated that dental institutions need at least 208 to 218 new faculty members each year, based on a faculty turnover rate of approximately 33 percent every 5 years.
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Curriculum Needs
New technologies such as telehealth, bioinformatics, and virtual reality, as well as databases specifying human, animal, and microbial genomes, are altering public awareness, attitudes, and behavior regarding health issues. The new knowledge and tools available are also changing dramatically how health care professionals are taught, how they learn, how they practice, and how they retain clinical practices.
These developments, along with new paradigms for the treatment of oral, dental, and craniofacial diseases and disorders, have led to several recent studies of oral health professional education and curricula (Field 1995). A 1995 Institute of Medicine study on the future of dental education called for greater integration and collaboration of dental schools with the parent university and academic health center, a commitment to research programs and the building of research capacity, and an enrichment of the curriculum to incorporate new scientific knowledge and its transformation into clinical applications. The report’s first strategic policy principle affirmed that “oral health is an integral part of total health, and oral health care is an integral part of comprehensive health care, including primary care.” Ideally, curricula for all health professional schools should reflect this principle by integrating knowledge and management of oral and medical health and disease.
Work is beginning on revisions to educational materials necessitated by these advances in research and technology. Initial steps are being taken to increase emphasis on interdisciplinary training, clinical research, and orientation to cultural competency in health professional education. The National Coalition for Health Professional Education in Genetics is promoting the incorporation of genetics, genomics, and proteinomics into predoctoral programs to prepare future health professionals to integrate genetics into practice. Other developments that need to be addressed include HIV disease and other emerging and reemerging infectious diseases, increased understanding of gender health issues, management of chronic pain, and the growing numbers of aging baby boomers and older Americans with complex and chronic health problems. For example, instruction on the special needs of individuals whose oral health is compromised by systemic diseases or disease treatments and on the heightened quality-of-life expectations of young and middle-aged adults should be incorporated into the curricula. In addition, in Area Health Education Centers in some states, health profession students work together to care for patients in underserved, rural, or disadvantaged populations.
The HIV/AIDS Dental Reimbursement program assists dental education programs in meeting the HIV/AIDS community’s significant need for oral health care services. This program trains dental students and residents in the care and treatment of those living with this chronic disease. A federal-institutional partnership provides funds to dental education institutions to partially reimburse for the costs of providing oral health care services to people living with HIV and AIDS.
As the health professional curriculum evolves, so must efforts in K-12 education and beyond to improve the public’s health literacy. Efforts directed toward improving science and health knowledge and attitudes and at implementing health-promoting practices have begun; these can contribute to an enhanced partnership between patients and their health care providers.
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Taking Care of Those Most in Need
The capacity to care for those most in need requires not only an adequate number of individuals to provide the care, but also an equitable distribution of providers to ensure the availability of care. In addition, sufficient financial resources must be available to support the delivery of and reimbursement for care provided to those most in need. Attention must also be given to a quality of care that ensures that the services provided fulfill the needs and functional requirements of the patients. Although the proportion of the population that uses dental services continues to increase, disparities remain (see Chapter 4).
A recent review of the literature related to access to care has identified many of the factors associated with these disparities. The lack of dental insurance emerged as a highly significant factor (Isman and Isman 1997). A series of reports demonstrates that privately insured individuals of all ages are more likely to get dental care when they need it than are the uninsured (Bloom et al. 1997, Cohen et al. 1997, Simpson et al. 1997). Lack of insurance was found to be an even more significant barrier to gaining primary care access for children than either poverty or minority status (Newacheck et al. 1997).
Once access to care has been established, there is greater likelihood that individuals will adopt preventive practices. Although a causal relationship has not been established, Wagener et al. (1992) found that brushing with a fluoride dentifrice and using dietary fluoride supplements were more frequent among preschool children who had had a dental visit in the past year than among those who had not. In contrast, as discussed in Chapter 4, one of the most common reasons cited by individuals in all income and education groups for not having made a dental visit was that they did not perceive that they had a problem. This implies a lack of awareness that attaining and maintaining good oral health and preventing disease require not only self-care but also professional oral health care.
Federal and state statistics show strong and consistent racial and ethnic disparities among U.S. children in disease occurrence and severity, untreated dental disease, access to dental care, and use of preventive services (see Chapter 4). Vulnerable child populations as well as the elderly, individuals with disabilities, people with HIV, migrant workers, and homeless persons pose an additional set of challenges. These populations require health care providers sensitive to cultural and social issues who are capable of addressing complex problems that demand integrated dental and medical care. The oral, dental, and craniofacial and medical care curricula are vital in preparing dental and other health care providers to coordinate and integrate care for these individuals.
The issues of oral health and the underserved have been addressed in a policy paper, Oral Health for All: Policy for Available, Accessible and Acceptable Care (Warren 1999). This report makes recommendations regarding financial barriers to care, integration of oral health services into health care delivery, capacity to meet oral health needs, cultural competency of health care providers, and education and oral professional practice requirements to meet the oral health care needs of underserved populations.
A survey of dental care reported that more than half of the responding private practice dentists provided some charitable care to low-income populations in 1996 (ADA 1998b). Although access-to-care dental programs for low-income populations are supported by many dental societies, this generosity falls well short of meeting the needs of these populations, which also require community-based programs (Waldman 1999) (see Chapter 7). Programs such as Community and Migrant Health Centers serve hard-to-reach populations. In 1996, more than half of such centers provided dental services, serving more than 1 million people (J. Anderson, personal communication, 1999).
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TWENTY-FIRST CENTURY CHALLENGES: WHAT LIES AHEAD?
The United States is witnessing unprecedented changes in demography, patterns of disease and disorders, and the nature of health care. The imperative to keep abreast of advances in science and technology is already evident in dentistry and medicine, aided by access to multiple information systems. In addition to the Internet and continuing dental education, the new century will see continued growth in imaging systems, computer-assisted technology, teledentistry and telemedicine, improved diagnostics and therapeutics, and new biomaterials and other biotechnology products. Genetic information will play an increasing role in assessing a patient’s risk for disease and in planning treatments.
Although some information is available on the effectiveness, cost-effectiveness, and outcomes associated with health care treatment, further research will be needed to determine “best practices”—which treatments work for which patients, under what circumstances, and at what cost. Treatment planning will incorporate outcome measures and patient preferences. Systematic reviews of the existing literature will help promote an evidence-based approach to dental and medical care. In addition, comprehensive diagnostic and treatment codes, as well as a process by which new technologies can be incorporated appropriately, will be needed.
The dental profession has been at the forefront of efforts to prevent disease and enhance general health and the quality of life. Efforts such as community water fluoridation, over-the-counter fluoride products, and dental sealants represent a preventive orientation that has been associated with the dental profession for half a century. Dentistry is continuing to be responsive to the ever-rising expectations of patients. Increases in the provision of fee-for-service cosmetic dentistry, adult orthodontics, and dental implants are among the trends already in evidence and expected to grow.
As the knowledge base regarding the relationships between oral health and general health increases, so too will the need for greater coordination of dental and medical services. Efforts to improve cardiac care, for example, may include treatment of periodontal diseases. Prenatal care may come to include a dental evaluation and treatment to reduce the risk of preterm, low-birth-weight deliveries. Regular oral examinations and periodontal treatment for diabetic patients may become an important component in disease control. Partnerships will need to be expanded and new ones created among the private dental, medical, and public health components.
A challenge facing the health professions will be to expand community-based disease prevention and personal oral health care to meet the needs of populations. Questions of access and barriers to care must be addressed and satisfactory solutions found to ensure that there is care for all who seek it.
The extent to which these predicted structural, organizational, and thematic changes will affect the nation’s capacity and commitment to provide oral health care is not certain. The nation’s health promotion and disease prevention objectives, which include oral health objectives, serve as a critical guide. How successful a changed care system will be in addressing the oral health needs and wants of the nation can be measured in several ways. These include reductions in health disparities in the population, decreases in the overall incidence and prevalence rates of diseases for the entire population, improved functional status, lower costs, reduced mortality rates, and enhanced health and quality of life.
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FINDINGS
- Dental, medical, and public health delivery systems each provide services that affect oral and craniofacial health in the U.S. population. Clinical oral health care is predominantly provided by a private practice dental workforce.
- Expenditures for dental services alone made up 4.7 percent of the nation’s health expenditures in 1998—$53.8 billion out of $1.1 trillion. These expenditures underestimate the true costs to the nation, however, because data are unavailable to determine the extent of expenditures and services provided for craniofacial health care by other health providers and institutions.
- The public health infrastructure for oral health is insufficient to address the needs of disadvantaged groups, and the integration of oral and general health programs is lacking.
- Expansion of community-based disease prevention and lowering of barriers to personal oral health care are needed to meet the needs of the population.
- Insurance coverage for dental care is increasing but still lags behind medical insurance. For every child under 18 years old without medical insurance, there are at least two children without dental insurance; for every adult 18 years or older without medical insurance, there are three without dental insurance.
- Eligibility for Medicaid does not ensure enrollment, and enrollment does not ensure that individuals obtain needed care. Barriers include patient and caregiver understanding of the value and importance of oral health to general health, low reimbursement rates, and administrative burdens for both patient and provider.
- A narrow definition of “medically necessary dental care” currently limits oral health services for many insured persons, particularly the elderly.
- The dentist-to-population ratio is declining, creating concern as to the capability of the dental workforce to meet the emerging demands of society and provide required services efficiently.
- An estimated 25 million individuals reside in areas lacking adequate dental care services, as defined by Health Professional Shortage Area (HPSA) criteria.
- Educational debt has increased, affecting both career choices and practice location.
- Disparities exist in the oral health profession workforce and career paths. The number of underrepresented minorities in the oral health professions is disproportionate to their distribution in the population at large.
- Current and projected demand for dental school faculty positions and research scientists is not being met. A crisis in the number of faculty and researchers threatens the quality of dental education; oral, dental, and craniofacial research; and, ultimately, the health of the public.
- Reliable and valid measures of oral health outcomes do not exist and need to be developed, validated, and incorporated into practice and programs.
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