Slide 1: Ryan White CARE Act Dental Reimbursment Program (DRP) 2005 Data

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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 2005 program funds were awarded to defray the non-reimbursed oral health service costs incurred during the 2003 - 2004 service year.
• A total of 66 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 broaden and 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 66 DRP applicants who submitted data were located in 24 states, the District of Columbia, and Puerto Rico. Of these programs:

• 19 were Predoctoral 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.
• 46 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.
• 1 was a Dental Hygiene Education Program

Slide 5: United State map of CBDPP and DRP Program providers

Slide 6-8: Program Attributes

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. Others provide services in other clinics within the medical center, including infectious disease clinics and the operating rooms.
• 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 service delivery utilizing mobile clinics to serve hard-to-reach populations.
• 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, especially using their students and residents.
• A number of DRP applicants have started offering unique services designed to connect affiliated sites and thereby extend training to providers and services to patients. The use of technology such as telemedicine, distance learning and videoconferencing to connect affiliated sites of care and training are increasingly being developed within community-based sites.
  
• An important component of many programs is the availability of dental specialists and urgent care. 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 / HIV Status

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• More than four in ten (44% or 13,627) patients cared for by DRP applicants have the HIV disease that has not progressed to full-blown AIDS.
• About three in ten (29% or 9,151) patients have CDC-defined AIDS.
  
• Almost an equal proportion (27% or 8,272) was reported to be HIV-positive, but their AIDS status was unknown.

Slide 10: Patient Charactersitics

• Dental Reimbursement Program applicants reported serving 31,050 individuals with HIV.
• 9,605 individuals or 31% received care from Predoctoral Dental School programs, while 21,410 or 69% received care from Postdoctoral Dental Residency Programs.
• Of the total number of individuals reported receiving care, the largest number (21,722 or 70%) was served by programs in the Northeastern states. This was followed by programs in the Southeastern and Western states (3,448 or 11% and 3,414 or 11%, respectively).
• Slightly less than one half of all reported DRP patients (14,156 or 46%) received care in programs located in NY state.
  

Slide 11: Gender Distribution of Individuals Served

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• Overall, 19,813 or 64% of the individuals served were males while 11,072 or 36% were females.
• Programs located in FL reported that more than six in ten (65%) of their patients were females. Programs in four other states – DC, MO, NY – reported that more than 40% of their patients were females.
  

Slide 12: Age Distribution of Individuals Served

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• About one in two individuals (52%) who received care were 25 - 44 years of age.
• Programs in KY, MN, MO and OH reported that more than six in ten (60% – 75%) of the patients they served were in the 25-44 age group.
• Programs in PR and NE reported a substantial majority (71% and 83%) of their patients as being in the 45-64 age group. Programs in CT, IL, NC, and WA also reported more than half (50% - 64%) of their clients to be in the 65+ age category.

Slide 13: States with Programs Serving the Highest Number of Children and Youth

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• Of all DRP clients, 1,993 or 6.4% were children and youth age 0-24 years.
• Programs in the Northeast region reported serving the majority (84%)of the children and youth.
• Over six in ten (1,321 or 66%) were served by DRP applicants in NY alone. Although children and youth constitute only 4.7% of New York’s patient load, this represents the highest number of children and youth served by any state.
• The provider in MO reported a substantial proportion (29%) of their total caseload in this age group.
• Programs in DC, MN, and LA, reported higher than average proportions (10.6%, 5.1%, 5%) of their total case load in these age groups.

Slide 14: Ethnic Distribution of Individuals Served

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• 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.
• A total of 9,160or one in three (30%) of all patients served by the DRP are of Hispanic or Latino/a ethnicity.
• All patients (100%) in PR, and more than four in ten (45%) in NY were of Hispanic ethnicity. FL, MA, and CT also cared for substantial proportions of people of Hispanic ethnicity (39%, 30%, and 27%, respectively).

Slide 15: Race Distribution of Individuals Served

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Slide 16: Populations Served

• Blacks/African-Americans and Whites each make up about four in ten (44%, and 40%) respectively of all patients served.
• Minority groups in general make up more than four in ten (46%) of the DRP patients, and most (96%) of these are Blacks/African-Americans.
  

Slide 17: Household Income

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• Of the 31,050 clients served by the DRP, over four in ten (43% or 13,423) are reported to be at or below the federal poverty line (FPL). Another 16% or 4,850 are just above this threshold (101%-200%).
• Programs in MD and NC reported almost all their clients (93% and 95%, respectively) to be at or below FPL.
• Three other states (DC, MS, and PA) reported about eight in ten (87% - 89%) of their clients to be at or below federal poverty level.

Slide 18: Pregnant HIV+ Women Served

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• A total of 151or 1.4% of all female patients cared for by DRP participating institutions were reported to be pregnant women with HIV. Another 463 or 4.2% were unsure if they were pregnant.
• The majority (82% or 123) of all pregnant patients were cared for by postdoctoral dental residency programs.
• 109 or 72% of these pregnant patients were cared for by programs in NY.

Slide 19: Number of Visits for Most Frequently Provided Oral Health Care Services

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• A total of 188,306 oral health care service visits were made to DRP institutions.
• 112,552 or 60% of these visits were made to Postdoctoral Residency programs, while 75,593 or 40% were made to Predoctoral Dental programs. Less than 1% or 161 visits were made to Dental Hygiene Education Programs.
• The most common service visits were for Diagnostic and Restorative care.
• Five categories of procedures (Diagnostic, Restorative, Preventive, Oral Surgery, and Prosthodontic) account for 122,622 or 65% of the total service visits

Slide 20-21: Location of Primary Medical Care

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• About four in ten (37.4% or 11,611) of DRP clients received primary medical care in the same DRP facility and site.
• About the same proportions (27.2% and 26.4%) received care in the same institution, but different site, as opposed to a different institution and site.
• One half of Post-doctoral Program clients (48.8%) were cared for in the same physical facility. However, the situation is reversed for Predoctoral Programs, with one half of their clients (51.4%) cared for in a different institution and site.
• Providers in eight states (FL, GA, LA, MN, MS, OH, PR, UT) provided primary medical care to all or nearly all (86%-100%) of their clients in the same facility. Providers in four states (MO, OR, TX, WA) provided all or nearly all (76%-100%) care in a different institution and site. Three other states (CA, MA, MD) also provided care to one-half of their clients in a different institution and site.
• About four in ten (37.4% or 11,611) of all DRP clients received primary medical care in the same DRP facility and site.
• About the same proportions (27.2% and 26.4%) received care in the same institution, but different site, as opposed to a different institution and site.
• One half of Post-doctoral Program clients (48.8%) were cared for in the same physical facility. However, the situation is reversed for Predoctoral Programs, with one half of their clients (51.4%) cared for in a different institution and site.
• Providers in eight states (FL, GA, LA, MN, MS, OH, PR, UT) provided primary medical care to all or nearly all (86%-100%) of their clients in the same facility. Providers in four states (MO, OR, TX, WA) provided all or nearly all (76%-100%) care in a different institution and site. Three other states (CA, MA, MD) also provided care to one-half of their clients in a different institution and site.

Slide 22: Third Party Coverage

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• One-half (47%) of the patients served by the DRP applicants had no third party insurance coverage to cover the costs of their care.
• Much of the other half have only partial coverage for their care.
• Providers in ten states report the overwhelming proportion of their clients (74%-99%) as having no other third payor insurance coverage

Slide 23: Payment Source for Oral Health Care Coverage

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• Medicaid (non-HMO) was the leading source of payment, covering 7,300 or 25% of all clients.
• A majority (6,356 or 87%) of these Medicaid clients were cared for by Post-doctoral programs

Slide 24: Payment Source and Coverage Amounts

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• One-half (51%) of the $4,031,760 of coverage amounts realized by participating institutions were from Medicaid (non-HMO)
  
• The majority of the Medicaid (non-HMO) funds (84%) were realized by Post-doctoral programs.
  
• About 9% or $356,000 of total coverage funds were self-pay or cash, and most of these were paid to Pre-doctoral programs
  

Slide 25: Number of Students and Residents enrolled in School or Program

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• The training of students, residents and providers is an important component of the oral health care services.
• A total of 13,753 students and residents were reported to be enrolled in all participating institutions and facilities, and most (9,573 or 70%) of these are enrolled in Pre-doctoral programs.
• More than one-half of the Pre-doctoral students and residents (52%) were reported by programs in three states – CA, MA and NY.

Slide 26: Students Receiving Formal Instruction on Oral Health Care for HIV+ Patients

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• Over 12,000 students, residents and other providers received formal didactic instruction in the medical assessment or oral health care management for patients with HIV.
• The majority (69%) of these care providers were reported by Pre-doctoral programs.
  
• DRP applicants in AL, CA, GA, KY, MI, OH, and OR reported that a majority of their students (73% - 99%) were in Predoctoral programs.
• Providers in MN, MO and UT reported that all (100%) of their students were in Post-doctoral programs.

Slide 27: Students and Others Providing Direct Clinical Care to HIV+ patients

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• A total of 7,447 oral health clinicians and others provided direct clinical services to HIV+ individuals.
  
• The majority of these students and others (74%) were reported by Predoctoral programs.
  
• More than six in ten (63%)of these providers were students in Predoctoral programs, and over seventy percent (71%) of the rest were students in Postdoctoral programs

Slide 28: Number of Clinical Hours Provided

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• Students, Residents and other providers spent a total of 238,665 hours providing clinical care to HIV+ individuals.
• Over 180,000 or 76% of these hours were reported by Pre-doctoral Programs.
• Nearly half of these service hours (48%) was contributed by Pre-doctoral students

Slide 29: Curriculum Hours Dedicated to Oral Health Care for HIV+ patients

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• A total of 131,073 education curriculum hours (required and elective) were dedicated by oral health institutions to HIV-related issues.
• All but a few (95%) of these were Required as opposed to Elective hours.
• More than sixty percent (63%) of these hours was part of Predoctoral Dental Education curricula.

Slide 30: Other Ryan White CARE Act Funding

Over six in ten (63%)Dental Reimbursement Programs reported that their parent institutions received funding from other CARE Act programs in 2004 (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 $29,744,936. Parent institutions with Postdoctoral Residency programs (mostly hospitals and community-based organizations) received 80% of these funds.

Ryan White CARE Act funding came from the following sources:

• $15,607,114 from Title I
• $3,761,494 from Title II
• $11,089,774 from Title III
• $4,918,716 from Title IV
• $504,871from Community-Based Dental Partnership Programs (CBDPP)
• $3,326,577 from Special Projects of National Significance (SPNS)
• $1,189,634 from AIDS Education and Training Centers (AETC) program

Slide 31: Patients and Reimbursed Amounts by Source

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• Nearly half (48% or 7,300) of all patients who had some reimbursed care had Medicaid (HMO). DRP institutions received a total of $672,000 from this Reimbursement source.
• About 30% or 4,571 of the patients who had some reimbursed care were covered by Medicaid (non-HMO). However, DRP institutions received half of the total reimbursed amount ($2 million) from this reimbursement source alone.
• DRP applicants in CT and WA reported that 75% of their patients who had partial reimbursement were on Medicaid (non-HMO).
• However, DRP applicants in GA, IL, LA, MO and MS reported that all or nearly all of their reimbursement amount (90% - 100%) came from Medicaid (HMO).
• DRP applicants in DC, MD, and TX reported that a sizeable portion (74%, 65%, and 100%, respectively) of their reimbursement amount came from Self-Pay or Cash.

Slide 32: Fiscal Characterstics

• Total non-reimbursed oral health care costs reported by all participating Dental Reimbursement Program applicants was $16,774,707
• Predoctoral Dental School Programs reported approximately $6.2 million in non-reimbursed costs.
• Postdoctoral Dental Residency Programs reported approximately $11.6 million in non-reimbursed costs.
• Applicants in New York state reported the highest amount of non-reimbursed costs, about $6.7 million.
• The sum of reported non-reimbursed costs totaled more than $1 million in each of five states - NY, CA, FL, KY and MA.

Slide 33: Institutions’ Unreimbursed Costs and DRP Awards: 1997 - 2005

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• Since FY97, DRP institutions have reported a total of $132.4 million in unreimbursed costs. Within that period a total of $78.1 million in DRP funds have been awarded to support applicants.
• Between 2001 and 2004, the reimbursement level of DRP awards was an average of 72 cents for every unreimbursed dollar reported.
• However, in 2005, DRP applicants received a median amount of $64,000, which was only 56 cents for every unreimbursed dollar they spent in providing care to HIV+ individuals.

Slide 34: Institutions’ Unreimbursed Costs and DRP Awards: 1997 - 2005

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• Notably the number of DRP applicants has been decreasing since 1997. In the period between 2000 and 2005, there was a drop-off from 85 to 66. However, the average non-reimbursed cost per institution has continued to increase.
• Overall, the average non-reimbursed cost of oral health provided by a DRP applicant rose from $130,325 in 1997 to $254,162 in 2005, an increase of almost 50%.
• Since 1997, Postdoctoral Residency Programs have reported higher non-reimbursed cost increases compared to Predoctoral Dental Programs.