[Senate Hearing 108-248]
[From the U.S. Government Publishing Office]
S. Hrg. 108-248
AGEISM IN HEALTH CARE:
ARE OUR NATION'S SENIORS RECEIVING PROPER ORAL HEALTH CARE?
=======================================================================
FORUM
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
WASHINGTON, DC
__________
SEPTEMBER 22, 2003
__________
Serial No. 108-22
Printed for the use of the Special Committee on Aging
U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2004
91-118 PDF
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001
SPECIAL COMMITTEE ON AGING
LARRY CRAIG, Idaho, Chairman
RICHARD SHELBY, Alabama JOHN B. BREAUX, Louisiana, Ranking
SUSAN COLLINS, Maine Member
MIKE ENZI, Wyoming HARRY REID, Nevada
GORDON SMITH, Oregon HERB KOHL, Wisconsin
JAMES M. TALENT, Missouri JAMES M. JEFFORDS, Vermont
PETER G. FITZGERALD, Illinois RUSSELL D. FEINGOLD, Wisconsin
ORRIN G. HATCH, Utah RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina BLANCHE L. LINCOLN, Arkansas
TED STEVENS, Alaska EVAN BAYH, Indiana
RICK SANTORUM, Pennsylvania THOMAS R. CARPER, Delaware
DEBBIE STABENOW, Michigan
Lupe Wissel, Staff Director
Michelle Easton, Ranking Member Staff Director
(ii)
C O N T E N T S
----------
Page
Opening Statement of Senator John Breaux......................... 1
Panel of Witnesses
Vice Admiral Richard H. Carmona, Surgeon General, U.S. Department
of Health and Human Services, Washington, DC................... 3
Greg J. Folse, Lafayette, LA..................................... 19
Appendix
Testimony of Daniel Perry, Executive Director, Alliance for Aging
Research....................................................... 61
Statement of Dr. Robert Collins, American Association for Dental
Research (AADR)................................................ 66
Statement by Teresa Dolan, American Association of Public Health
Dentistry...................................................... 72
Statement submitted by James Harrell, American Dental Association 78
Statement of Dr. Paula K. Friedman, Professor and Associate Dean
of Administration, Boston University Goldman School of Dental
Medicine, and President American Dental Education Association.. 83
Written statement of Karen Sealander, American Dental Hygienists'
Association.................................................... 98
Testimony of Jonathan Musher, MD, on behalf of the American
Health Care Association........................................ 124
Statement of Dr. Robert Barsley, Oral Health America............. 127
Statement of Robert J. Klaus, President and CEO, Oral Health
America........................................................ 132
Testimony of Dr. Paul Glassman, Associate Dean, Co-Director
Center for Oral Health for People with Special Needs,
University of the Pacific School of Denstitry, President,
Special Care Dentistry......................................... 137
Statement submitted by The Apple Tree Dental Model............... 143
Testimony of Kim Volk, President and CEO, Delta Dental Plans
Association.................................................... 150
(iii)
FORUM ON AGEISM IN HEALTH CARE: ARE OUR NATION'S SENIORS RECEIVING
PROPER ORAL HEALTH CARE?
----------
MONDAY, SEPTEMBER 22, 2003
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The Forum convened, pursuant to notice, at 2:05 p.m., in
room SD-628, Dirksen Senate Office Building, Hon. John Breaux,
presiding.
Present: Senator Breaux.
OPENING STATEMENT OF SENATOR JOHN BREAUX
Senator Breaux. If everybody would please find a seat, we
can begin our afternoon session, and I will do so by welcoming
everyone to what is really a forum this afternoon; it is not a
formal Aging Committee hearing, but it is an opportunity for
all of us who are interested in the question of health care for
our Nation's seniors to focus in on one particular aspect of
our Nation's health concerns and particularly dealing with our
Nation's older Americans, and that is the whole question of
proper oral health care, dental care, for our Nation's senior
citizens.
So I would like to welcome everyone to this session this
afternoon, and I want to thank the Chairman of the Aging
Committee, Senator Craig, for his cooperation and support and
assistance for allowing us to meet and have this discussion.
This afternoon we will focus on the question of whether
older Americans are receiving proper oral health care. I think
the purpose is really threefold--first, to define the oral
health issues that are facing our Nation's seniors today, and
second, to try to develop and discuss some potential solutions
to the problems that exist; and third, to alert Americans about
the opportunities they have to help improve health care,
particularly oral health care, for America's elderly.
Although there have clearly been dramatic improvements in
oral health care during the last 50 years, profound disparities
continue to exist for those without the knowledge, the
resources, or the capability to achieve good-quality oral
health care.
This certainly includes our poor and vulnerable elderly and
disabled adults, and poor oral health care causes suffering to
millions of Americans and obviously particularly to our most
vulnerable population.
Twenty-three percent of the 65- to 74-year-olds have severe
periodontal or gum disease. The percentage of risk increases,
of course, as people age. People at the lowest socioeconomic
levels have even more severe periodontal disease. Oral and
pharyngeal cancers are diagnosed in about 30,000 Americans
annually, and 8,000 die from these diseases every year, which
are primarily diagnosed in the elderly, and their prognosis is
very poor.
Fewer than 2 out of every 10 older Americans are covered by
private dental insurance. Uninsured Americans with severe oral
disease often end up in hospital emergency rooms, where the
problem is addressed with painkillers and/or tooth extractions,
both of which are obviously only a temporary fix, wasting
millions of taxpayer dollars every year.
Recent research has further highlighted the results of poor
oral health care. Studies have shown a connection between
chronic oral infections and heart and lung disease and stroke
and diabetes and premature birth. Infections resulting from
oral infections place individuals at serious risk of death.
Infectious diseases of the mouth left untreated can cause undue
pain and suffering and poor quality of life, and even death.
Clearly, all Americans need to be aware of the need for
good oral health. However, our emphasis today is on grappling
with how best to ensure that our older Americans receive proper
oral health care. It is my hope that this forum will accentuate
the importance of oral health.
Thanks to the generous support of Oral Health America, we
are releasing a report today entitled ``A State of Decay: Oral
Health of Older Americans.'' As you can see from the charts
behind me, Oral Health America surveyed all 50 States and the
District of Columbia on the extent of the oral health care
services for Medicaid adults. As a part of this study, a report
card was developed that reflects predominantly failing grades
in all jurisdictions, giving the United States a score of ``D''
as our national average. It is very alarming, considering the
severe health consequences and resulting cost of poor oral
health care.
I thank each and every one of you for being with us and for
your participation and look forward to hearing from you as we
discuss this issue.
I would first like to welcome the Surgeon General, who is a
surgeon but not a general, but he is an admiral, and we are
very pleased to welcome Vice Admiral Richard Carmona, who is
our Surgeon General. Vice Admiral Carmona was sworn in as the
17th Surgeon General of the United States Public Health Service
in August 2002. He is a decorated veteran and graduate of the
University of California Medical School. Dr. Carmona has
published extensively and received numerous awards,
decorations, and local and national recognition for his
achievements. We thank him for participating and for his
support.
I would also like to introduce Dr. Greg Folse, who is a
practicing dentist from Lafayette, in my State of Louisiana. He
was instrumental in drawing my attention in the beginning to
the critical issues surrounding oral health of the elderly. He
has a mobile geriatric dental practice and also works with the
American Dental Association and Special Care Dentistry to
improve oral access for special needs patients. He is really
very passionate about caring for the oral health of the elderly
and carries out that mission every day of his life.
I have seen the slide presentation that Greg will make to
us this afternoon. It is most impressive in highlighting the
serious nature of the problem that we face as a Nation.
I would also like to say thanks to all of the organizations
represented here this afternoon. I am pleased to introduce
these organizations and the representatives who are here today.
Your biographies are all included in our official record, and I
will simply recognize you for the sake of brevity:
From the Alliance for Aging Research, Dan Perry. Dan, thank
you for being with us; from the American Association for Dental
Research, Dr. Robert Collins; from the American Association of
Public Health Dentistry, Dr. Teresa Dolan; from the American
Dental Association, Dr. James Harrell; from the American Dental
Education Association, Dr. Paula Friedman; from the American
Dental Hygienists' Association, Karen Sealander; from the
American Health Care Association, Dr. Jonathan Musher; the
CMMS-HHS chief dental officer, Dr. Conan Davis; from Louisiana
State Dental Medicaid Services, Dr. Robert Barsley; from Oral
Health America--thank you for the good work--Dr. Robert Klaus;
from Special Care Dentistry, Dr. Paul Glassman.
Thank you all.
I would like to also introduce Janet Heinrich, who is with
GAO, the Government Accounting Office's Director of Health Care
and Public Health Issues. She has put together and led many of
the health studies that we have utilized, both in the Finance
Committee and in our committee on elderly issues, for the U.S.
Senate and for the Congress, and we appreciate once again her
doing the work. We are going to ask her to moderate if I have
to leave some of the discussion, Janet, if that would be all
right with you.
Ms. Heinrich. Yes.
Senator Breaux. Our format will be to first hear from our
Surgeon General, Dr. Carmona. If you would go ahead and lead us
off, we would appreciate hearing from you, and then we will go
to Dr. Folse and his slide presentation.
Mr. Surgeon General, we are delighted to have you with us.
STATEMENT OF VICE ADMIRAL RICHARD H. CARMONA, SURGEON GENERAL,
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC
Dr. Carmona. Thank you, Senator. It is nice to be here.
Thank you for taking the leadership in this very important
area.
My name is Richard Carmona. I am the United States Surgeon
General, and as an American, I want to take this opportunity to
thank all of you for the service that you have provided to the
Nation in keeping this very important issue on the forefront.
I have had the honor of working with many of you during my
first year as Surgeon General and look forward to strengthening
our partnerships to improve the health and well-being of all
Americans.
Senator, you have been a leader in addressing the health
needs of America in general and its seniors, and I thank you so
much for continuing to take the lead in those issues. It was a
pleasure participating with Senator Craig, another leader, just
recently in a Montana Health Summit, and Senator Burns, who
also understand the value of public health and keeping our
citizens healthy.
Today I welcome the opportunity to talk with this committee
about the oral health of America's seniors. While oral health
is tremendously important, I am sure I do not have to tell you
that it does not receive much attention. For that reason, I
appreciate the focus of this forum, especially in the context
of a holistic approach to disease prevention.
Poor oral health adversely affects all aspects of life.
Kids cannot learn in school if they are in pain. Adults miss
work due to dental pain and tooth and gum decay. Twenty-two
percent of adults report having some oral pain in the past 6
months. Oral and pharyngeal cancers, primarily found in the
elderly, are diagnosed in about 30,000 Americans annually.
Tragically, 8,000 Americans die from these diseases each year.
``Oral Health in America,'' a report of the Surgeon
General, recognizes that such oral health is essential to
general well-being and that the oral health of America's
seniors is today an acute problem. The facts are staggering.
About 30 percent of individuals 65 years and older have lost
all their teeth. The rate of oral and pharyngeal cancers is
higher among seniors than for any other age group. Americans 65
years and older are seven times more likely to be diagnosed
with oral cancer than younger individuals.
The vast majority of payment for dental services is out-of-
pocket for older people, with only rare exceptions. Medicare
does not cover the cost of oral health services. This results
in compromised access for our seniors. While 61 percent of the
general population reports having a dental visit in the past
year, only 45 percent of seniors 75 years and older report
seeing a dental professional in that same time period.
A number of HHS programs focus on oral health needs of
seniors. HRSA's oral health program is increasing access to
oral health care through its 843 health center grantees.
Seventy-two percent of these centers offer preventive dental
care. Also, NIH's National Institute of Dental Health of Dental
and Craniofacial Research reports many clinical trials related
to the oral health of seniors.
In addition, CDC's division of oral health supports oral
health projects in predominantly poor, ethnically diverse
communities. These projects include: mobilizing community
health workers to improve oral health practices in rural
Alabama; setting up an oral health training program for nurses
who care for homebound seniors in Harlem, which is my old
neighborhood; and in Washington State, training seniors to be
oral health educators for children, which improves the health
of the kids and the seniors.
As you know, in April of this year, I released a National
Call to Action to Promote Oral Health. The Call to Action is a
guide for our efforts to improve oral health. It outlines five
action areas.
First, we need to change the perceptions of oral health. We
can no longer afford to have Americans believe that oral health
is separate from general health and well-being. Improving
health literacy is key to improving America's oral health.
Second is to replicate effective programs and proven
efforts. Best practices in oral health must be recognized and
replicated in every State.
Third is to build the science base. Biomedical and
behavioral research is transforming our knowledge of
prevention, diagnosis, and treatment of oral diseases. This
knowledge must be turned into action.
Fourth is to increase oral health workforce diversity,
capacity, and flexibility. Women and minorities are under
represented in the dental profession. We must encourage
diversity and use culturally competent messages to eliminate
disparities in oral health.
Fifth and finally is to increase collaborations. Disease
prevention and health promotion campaigns that affect oral
health, such as proper brushing and flossing and regular
checkups, as well as tobacco control and nutrition counseling,
can lead to improved oral health for all Americans.
The prevention message that President Bush, Secretary
Thompson and I have been emphasizing is applicable to ensuring
good oral health. For example, there are simple steps that any
person can take to prevent dental diseases. They are: proper
brushing and flossing; use of fluoride rinse or toothpaste;
regular visits to the dentist; healthy eating; limiting alcohol
use and avoiding tobacco.
In particular, tobacco use, whether cigarettes, cigar, or
smokeless tobacco, frequently results in oral cancers. Most
people, even many health professionals, do not know that
smoking causes over 50 percent of the periodontal disease in
the United States.
We need to get this information to the public and to health
professionals. Again, it is an issue of health literacy. It is
a battle in many areas of public health that I find, increasing
health literacy so that people understand the good science that
we have already available and we are not using it fully.
In closing, I will add that today must be a day of change.
Today must be a day when our work is a catalyst for better oral
health. I thank you for many efforts on behalf of seniors, and
I promise to work with you to improve the health and well-being
of all Americans.
With that, I will end my oral remarks. I would ask to be
able to submit my entire written statement into the record, and
I would also be happy to answer any questions, Senator.
Thank you very much.
Senator Breaux. Thank you, Dr. Carmona.
I understand that you need to catch a plane, so we are not
going to keep you too long. I am going to let you be excused
whenever you feel that you have to.
Dr. Carmona. Thank you, sir.
Senator Breaux. But I want to thank you for your
participation. I think that a lot of people do not understand
the serious nature of the problem, and I think that you as the
Surgeon General obviously have the capacity to highlight the
serious nature of oral health care for seniors at a time when
many Americans seem to be more concerned about the color of
their teeth; they want to make them whiter, and there are more
and more products for whiter teeth and how you can get them to
be brighter and brighter. There are many older Americans who
are suffering very severe health problems, not because of lack
of white teeth but because of severe infections and other
problems that they have.
So in your capacity as Surgeon General, I think it is
important that you make the statement that you made today and
continue to try to highlight this as a particular problem and a
particular concern.
So we thank you for being with us and hope you can continue
helping to educate the American public about this very serious
problem.
You may be excused whenever you have to go because you have
told me that you need to catch a plane for a trip.
Dr. Carmona. Thank you, Senator.
I would just add that, as I said when we released the
report, you have my full commitment as does the American public
in keeping this area of oral health on the forefront.
Thank you, sir.
Senator Breaux. Thank you, Admiral.
[The prepared statement of Dr. Carmona follows:]
[GRAPHIC] [TIFF OMITTED] T1118.001
[GRAPHIC] [TIFF OMITTED] T1118.002
[GRAPHIC] [TIFF OMITTED] T1118.003
[GRAPHIC] [TIFF OMITTED] T1118.004
[GRAPHIC] [TIFF OMITTED] T1118.005
[GRAPHIC] [TIFF OMITTED] T1118.006
[GRAPHIC] [TIFF OMITTED] T1118.007
[GRAPHIC] [TIFF OMITTED] T1118.008
[GRAPHIC] [TIFF OMITTED] T1118.009
[GRAPHIC] [TIFF OMITTED] T1118.010
[GRAPHIC] [TIFF OMITTED] T1118.011
[GRAPHIC] [TIFF OMITTED] T1118.012
Senator Breaux. Now let us ask Greg to make his slide
presentation, and then we will be able to begin the dialog that
I hope we can get on trying to find out what we need to be
doing.
Dr. Folse.
STATEMENT OF GREG J. FOLSE, LAFAYETTE, LA
Dr. Folse. I want to thank you very much, Senator Breaux,
for bringing us all together today.
You talked about the whitening--I think the color that my
patients would really like to have their teeth is ``some.''
Unfortunately, that is where we are.
That is one of the things that Louisiana happens to do
well, actually. We have a good denture program for our elderly,
but we do not pay for a lot of other things.
I also want to thank Dr. Carmona in his absence for his
call to action. I think it is already affecting lives. But we
have a long way to go.
Ageism and oral health--are our Nation's seniors receiving
proper oral health care? The answer is resoundingly no--they
are not receiving it right now when you look across the board.
The Surgeon General's report in 2000 called it ``a silent
epidemic'' for our elderly. I think that when you really look
at it, and you see the patients that I see--and let me back up
a little bit. I have a mobile geriatric practice, and I go to
nursing homes every day; I am in there day in and day out. When
you see what I see, it is not silent--it screams. It screams
for us to take action on the issue.
This is Miss Sylvia. I am going to introduce you today to a
few patients of mine, and if you cannot see, please get up and
move around; that is fine with me. Ms. Sylvia was the mother of
a nursing home administrator. She had just arrived at the
facility. She was poor. She had been in the community. You will
notice her hair is pretty; she has it all combed. She was
really trying to take care of herself. She has lipstick and
rouge, and everything was Cadillac-ing for her--except when you
looked in her mouth.
She did not have access to oral health services. She did
not go and have her teeth cleaned. She had gum disease. She had
broken teeth. She had abscesses in the back of her mouth. She
had infection.
We cannot stand for this. Her daughter cared dearly for her
and did not really realize that this was going on.
This is Mr. Joe, an old man in a facility--I work in
facilities all day, and I love nursing facilities. It is not
that he was there, but there is a great burden of disease when
these patients get into nursing facilities, and that burden is
difficult for us to deal with.
He had a tooth, which you can see right her, that they
asked me to take a look at. When I did, they told me his story.
He was a grumpy guy who would sit in his wheelchair and
literally run the wheelchair into your ankles. He was ornery
and hated everybody, and nobody liked him.
Well, when I looked in his mouth, under his lip was this
huge squamous cell carcinoma. This guy thought he was dying;
his face was rotting off. This cannot be. Had he had one dental
evaluation, one cleaning, while he was getting older, someone
would have picked this up.
We did radiation therapy, this became a little scar, and
the guy did very well. He started going to bingo and became a
good part of the facility.
Who are these patients? When I look at the country, I had
this term introduced to me not too long ago--the ``aged, blind,
and disabled.'' If we can think about our seniors and our
vulnerable adult population and use this term, we will be ahead
of the game, because this term is defined in Social Security
law, so it is a great place to hang our access hat.
This gentleman, Mr. Charles, is a good representative of
``aged, blind, and disabled.'' He is all three of them. He was
in a facility, and I told him 2 months ago, ``I am going to
Washington. I am going to try to get some help for your
teeth.'' He was all happy, and he gave me this kind of
convoluted smile that you can see here. He was happy about it.
He allowed me to take photographs of his mouth, and today
he sits in this facility with no access to oral health care
with these teeth. This is how he eats every day. He has broken
teeth, he has gum disease, he has abscesses. These are teeth
that are broken off at the gum line, for those of you who do
not know.
When I told him that I was going to Washington just to
talk, he thought I was going to take his teeth out that day,
and he got angry; and when he did, this was the face he made,
and I just quickly took a shot of it. I am with you, Mr.
Charles; I feel the same way. Let us do something.
How many of them are there? In my written testimony, I have
some actual numbers of disabled adults, but we all know that
the number of seniors in our country is going through the roof.
Just like Miss Marsha--these slides I took a month ago--6
months ago, she had an abscess for this little tooth, right
here. This tooth needed extraction 6 months ago. There is no
access in our State, along with other States--I will tell you
how many in a little while. I put her on antibiotics. Someone
else put her on antibiotics a month later, and someone else
again a month after that.
A $100 extraction would have taken care of this. The fourth
time she got infected, she got an MRSA infection, which is a
staph infection that is resistant to antibiotics. She had to go
in the hospital--and that is where these pictures were taken--
so that they could do a little surgical procedure, a drainage
here. During the procedure, she was septic, and her heart
stopped beating, so she went into the ICU for 4 days. One
hundred dollars for an extraction, $30,000 for a surgery and
ICU stay. It does not make a lot of sense, besides the
suffering that this lady had to go through.
As a practitioner, it kills me, because they sit and they
rot under my care, and I hate it. Guys like me all across the
country see the oral health of our seniors is neglected.
The report from the Surgeon General said there are many
disparities, and there are. The elderly take the brunt of it.
If you have money, you can get care--until you get medically or
functionally disabled, or until you get institutionalized or
you spend all of your money. Then you start losing that access
that we all have as functional adults.
Within the ``age, blind, and disabled''--and I realize this
is not quite as on-point--but we have mentally retarded adults
in our country who sit in facilities or who sit at home with no
access to oral health care. This is a sin that our mentally
retarded do not have access.
This poor gentleman sits--he is losing his teeth, he has
gum disease, he has abscesses--and there is nothing I can do
about it. There are hundreds and thousands of them across the
country like this. We have to do something on a national level.
I wish the Surgeon General was here for this. We need a
statement from him saying that oral health services are
medically necessary for this vulnerable population. I think
that is going to be a key to the advocacy or the push to get
services.
It goes on and on, people. I saw this guy, and 2 years
before I took this photograph, these four teeth were in perfect
shape; he had a $900 partial hooked to it that he was eating
with. Two years later, after a stroke, he has gum disease, he
bleeds every time he eats--and no access to care.
This is the old tooth in the lung, another $100 extraction
that turned into a $40,000 or $50,000 surgical procedure and
hospital stay with all these complications. A loose tooth--she
rolled over, hit her mouth on the bed rail, and it went into
her lung.
This is a birth mark. Miss Mary had this birth mark all her
life. But what I want you to look at are her eyes. Do you see
that? Two weeks before I took these photographs, Miss Mary was
walking and talking. She developed a dental abscess. Had she
had any access over the last few years of her life, they would
have caught something.
Miss Mary, you can see, is swollen here; actually, she has
some purulent drainage down on her bib. This was in the front
of her mouth. I would think that this tumor would have been
caught by somebody had we had access to oral health for an
aged, blind, and disabled adult. She could have gone somewhere.
Miss Mary died from the infection that got into this tumor.
They could not take care of it. Seven days after I took these
photographs, she passed away and really has solidly put the
need for what we are doing here today in me.
My wife will kill me, but I offer my services to all of you
as we go through this process of getting access for these
patients to help in any way I can.
What benefits are available? The Surgeon General talked
about it. There is virtually nothing until you get down to
Medicaid--virtually no Medicare, private insurance, applied
income laws. Medicaid has optional programs for every State.
States can individually choose whether they want dental
services or not.
This is what our country looks like--blue is a B; New York
gets a B--as far as Medicaid services go. The green States are
C's. The yellow States are D's, and the red States are F's. I
got to pick the colors, too--it is pus yellow and blood red--
and I am not going to apologize for it. It is a sin.
We have 45 States with a D or an F, and when you look at
the service reimbursements--and all of this is included in the
Oral Health Report Card from Oral Health America, which I thank
you guys for doing; it was great to be a part of that--when you
look at the service reimbursements for the providers out there,
all States except one get a D or an F.
So when I couple the D-minus grade for Medicaid with the
vulnerability of the ``aged, blind, and disabled,'' I give our
country an F on how we are doing.
Do we get it yet? There is nothing out there for these
adults. The system of optional Medicaid oral health benefits is
not working. We have in essence designated treatment of pain,
pus, infection, and swelling as ``optional,'' and it does not
make sense, and I know you all agree with me.
So nationally, unfortunately, we have no infrastructure for
oral health for ``aged, blind, and disabled.'' We do, however,
have an infrastructure for children under EPSDT, and this is
where I really think the solution can come. I believe that if
we could take the ``aged, blind, and disabled'' who are already
approved for Medicaid and put them into coverage under EPSDT or
in a system like that, I really believe that that would work.
National solutions--again, we need a bill, and I know that
you will be open to helping us with that with the ABD patients.
Within my testimony, I have included kind of the guts of that
idea of the ``aged, blind, and disabled oral health access
proposal''; it is in my written testimony. I would love to see
a declaration that oral health services are definitely
medically necessary. I would like to see the formation of a
National Oral Health Coalition for Special Needs Adults, and a
dental director in every nursing home.
It can be done well. This is Miss Daisy. I made these
dentures for her when she was 103 years old. Miss Daisy lost
them 4 years later, and I remade them. Miss Daisy wore those
dentures until she was 112 before she passed away. She had good
oral health, and it meant a lot to her. We can do that on a
national level.
I thank you all very much for being here, and I thank you
for participating in this event.
Thank you, Senator Breaux. [Applause.]
[The prepared statement of Dr. Folse follows:]
[GRAPHIC] [TIFF OMITTED] T1118.013
[GRAPHIC] [TIFF OMITTED] T1118.014
[GRAPHIC] [TIFF OMITTED] T1118.015
[GRAPHIC] [TIFF OMITTED] T1118.016
[GRAPHIC] [TIFF OMITTED] T1118.017
[GRAPHIC] [TIFF OMITTED] T1118.018
[GRAPHIC] [TIFF OMITTED] T1118.019
[GRAPHIC] [TIFF OMITTED] T1118.020
[GRAPHIC] [TIFF OMITTED] T1118.021
[GRAPHIC] [TIFF OMITTED] T1118.022
[GRAPHIC] [TIFF OMITTED] T1118.023
Senator Breaux. Thank you very much, Greg.
I met with Greg previous, and I had seen his presentation
back in Louisiana, and it was what really got me interested in
trying to figure out where we are as a Nation with regard to
oral health care for seniors.
Let me just start--and I want you all to enter into
discussion, not me--I would rather just sit and listen--but
Greg, you made a statement that Louisiana has a good program.
Dr. Folse. For denture care only.
Senator Breaux. Oh, for denture care. Explain the
difference between oral health care and just denture care that
we have in Louisiana.
Dr. Folse. Oral health care would include extractions,
would include all the preventive services, exams, x-rays,
getting teeth cleaned, gum disease treatment, fillings. That is
an oral health care program.
What we do is only the prosthetic side, which is a piece
and an important piece of oral health, but we make dentures. We
do not take out bad teeth to give you dentures, but we do
provide dentures for patients whose teeth are already gone.
Senator Breaux. That is really interesting; we are after
the fact.
Dr. Folse. The program was started years ago when most of
our elders--in our State, probably 65, 70 percent of our elders
had no teeth. Now I am seeing only about 40 percent; so I am
seeing 60 percent with teeth now. So back then when they
started that program, a majority of the population was affected
by it in a positive way. So it made sense back then.
Senator Breaux. So the State Medicaid program covers the
dentures?
Dr. Folse. Yes, sir, they do.
Senator Breaux. You are really pointing out something.
Older citizens, like my grandparents' generation, were just
expected to lose their teeth and never to have all of their
teeth.
Dr. Folse. Exactly, yes, sir.
Senator Breaux. OK. The information is obviously very
graphic. I think we have a problem, and the question is how
extensive is the problem. Can anybody talk about that a little
bit? I have seen Lafayette, and I have seen Louisiana, but what
about the study that we did with oral health?
Robert, do you want to comment on that? How did you all do
the survey?
Dr. Klaus. We surveyed Medicaid dental contacts across the
United States. I would suggest that the study results that we
see here today are really the tip of the iceberg, that the
problem is probably far more serious than even we would come
out and say.
Senator Breaux. What kinds of programs do we have for oral
health care among the States? I guess the States' obligation
would be under the Medicaid program for the low-income.
Dr. Klaus. Medicaid--but under the Medicaid program, the
first thing to be cut when times get tough in State
legislatures as they are now, with States facing huge deficits,
is the dental benefits of Medicaid. Recently, Michigan cut all
Medicaid benefits except for those that relate to emergencies.
We think that this pattern is going to continue. I just
heard this morning from people in Georgia that next year, they
think they are going to cut back on their dental benefits for
Medicaid.
Senator Breaux. Is the best that any State has under
Medicaid an optional program that covers dental?
Dr. Klaus. Yes. They are all optional.
Senator Breaux. They are all optional, and many of them do
not even have them as an option.
Dr. Klaus. No, many of they do not have them as an option.
Senator Breaux. Greg.
Dr. Folse. Correct. The children's program is not optional,
but all programs for adults are. You get a range of different
types of programs. Minnesota right now is doing very well with
their program. There are little problems within individual
programs, and as a whole, you have Medicaid issues nationally.
But it is optional versus non-optional.
So from Minnesota, which is doing well, treating a lot of
nursing home patients and a lot of elderly across the State, it
goes down to States with absolutely nothing, not even a denture
program; so you have us all in the range.
The effectiveness of those programs, though, comes in when
you really grade it, and that is what the report card did. We
cut out five different procedures and looked at the
reimbursement rates and said what dentist is going to do this
for these types of fees, and that is where we got all the D's
and F's. It was just way below what is out there.
Senator Breaux. We sent all of you some questions, and I
want to try to keep it focused to a certain extent. The first
question is: What is the greatest problem that seniors face
where oral health is concerned?
If you are poor, the greatest problem is you do not have
it. Anybody can start to comment on this. My father fortunately
has access to his employer's retirement health program that
covers dental care. He probably also has enough money that if
he did not have that insurance, he could afford to go to a
dentist and pay the bill.
But that is probably not the situation for most Americans.
Let us talk about that.
Paula.
Dr. Friedman. Senator, thank you for this opportunity to
comment. I think that this is a tremendously important issue,
and I would suggest that we consider, in additional to the
financial means to access care, the dearth of qualified
providers. One of the reasons that there is a problem certainly
is financial, but another level of problem is that there are so
very few qualified people trained in geriatric dentistry. A few
of them happen to be seated around this table. But I would ask
you to think about how many dentists are trained annually to
provide the special training to provide care to senior
citizens. I am not going to put you on the spot, but I am sure
you would not imagine. Under HRSA--and we are grateful for the
support that HRSA provides toward training geriatric physicians
and dentists--less than 10 dentists a year for the entire
country are trained in providing special services to this frail
elderly population with medically compromised, complex medical
conditions.
So I certainly recognize the financial aspect, no question
about that, but I am sure that my friend and colleague Dr.
Folse would agree with me that access is also a function of
having qualified providers.
Dr. Folse. Without a doubt. It is kind of what comes first,
the chicken or the egg, because I have had 3 years of extra
training so that I could take literally a 50 percent pay cut
over my colleagues. So what is going to come first? I do not
think we could get the--you almost have to have the financial
infrastructure at the same time. I do not care which one gets
there faster. We have got to do both of them, and you are
exactly right.
Dr. Friedman. You certainly have to address both. I happen
to be one of the dental directors of one of the HRSA-funded
geriatric dentistry and medicine training programs, so I can
tell you that there are only five to seven dentists per year in
the entire country.
Senator Breaux. Well, we only have five medical schools,
and we just recently picked up two more, but out of all the
medical schools in the country, 113 or so, there are only five
that offer graduate programs in geriatrics. It is the fastest
growing segment of our population in America, and yet only five
medical schools offer advanced degrees in geriatric
specialties. So when you break it down to subspecialties of
dentistry, you can understand why we only have 10 graduates a
year.
Yes, Mr. Harrell.
Dr. Harrell. I am a consultant to a nursing home, which I
do mostly on a free basis--I take a 100 percent cut--and we
have a Medicaid program that covers adults, although the
reimbursement rates are extremely low, sometimes as low as 14
to 16 percent of cost.
Senator Breaux. Who has the program?
Dr. Harrell. North Carolina.
Senator Breaux. Oh, the State does--under the Medicaid
program?
Dr. Harrell. Although we fear we are going to lose it. I
think the only reason we came out so well this year was the
one-time Medicaid reimbursement to the States which saved us
from probably a lot of lobbying and a lot of heartache. But
this is going to come back again next year. But it is a
financial issue. As a family dentist, I see geriatric patients
in my office on a daily basis. A lot of them have insurance or
can afford it otherwise, or they would have Medicaid. But going
into a nursing home facility--I serve three--there are no
facilities, no equipment. The nurses and staff know very little
about oral health, and most of the time you are doing
extraction in the middle of the night with a weak flashlight
battery, and they always feed them right before you get there.
I do not understand that. So I know we need geriatric
dentists--I am not underplaying that--but we need to stimulate
family dentists.
Senator Breaux. I would think--and I am obviously not a
medical doctor--but it would seem to me that the fact that we
do not have a lot of geriatric dental specialists, it seems to
me that any doctor of general dentistry can look at these
seniors and the problems they have are no different than those
of a young child who has not been to a dentist in 15 years of
his life. I mean, a practicing dentist would be able to look at
an elderly person just like he does a person who has never seen
a dentist who is 20 years old as the same types of problems
develop. There are a lot of other problems, particularly mental
illness and others, that seem to be a lot different among the
elderly and more difficult to recognize that it is a problem of
aging.
Dr. Harrell. There are special needs patients that you
cannot treat without some type of facilities, and in a lot of
places, we do not have those.
Senator Breaux. I would bet you there is not a nursing home
anywhere in the country that has a resident dentist.
Dr. Folse. I am actually a dental director in 14 nursing
homes now, and I am there usually a time or two a week, and we
do all of our services. I do do some extractions and cleanings
and those kinds of things at the facility----
Senator Breaux. But how many other dentists do that?
Dr. Folse. Not many. To build the infrastructure that we
are going to need to get people doing those kinds of services,
one of the things is to take away the yearly budgetary threat
that we get from Medicaid on a State-by-State basis. That has a
significant impact when you have a system built to treat
vulnerable adults, but it is always on target. I have trouble
getting other dentists to do that when the States pull the rug
out from under us every year.
Senator Breaux. But what kind of compensation does a
dentist who does what you do get? Is he reimbursed anywhere?
Dr. Folse. I am reimbursed for the denture care, and a lot
of the other stuff is donated.
Senator Breaux. We know these other problems are not
denture problems; they are just gum disease problems. You are
not going to be reimbursed zip for that.
Dr. Folse. But I am not treating it, either. It is sad. I
have 2,500 patients, and 1,600 patients have cavities and gum
disease under my watch, and they do not get treated. I put the
fires out as much as I can. I treat the ones that the families
will let me treat. But as a whole, having an infrastructure
where guys in an office could get paid to see these patients
and I could refer them to you would be great.
Senator Breaux. Are there any other comments from anybody?
Dr. Barsley.
Dr. Barsley. Senator Breaux, I appreciate the opportunity
to be here today.
I have worked with Dr. Folse over the years in Louisiana,
and one of our problems has been I have pulled the rug out from
under Greg more than once when our State ran out of funds; I
have reduced the amount of money that we can pay to him.
Fortunately this year, we were able to increase that amount of
money, and one thing we thought about doing was increasing the
services that were offered. Our problem was that the pent-up
demand is so vast that once we increase the range of services
we can offer, we have no way to judge how much pent-up demand
there would be; if we had to extract just one tooth in every
person in Louisiana who is Medicaid-eligible, that is one
million teeth.
Senator Breaux. How much do we pay for dentures?
Dr. Barsley. We pay roughly $1,000 in Louisiana.
Senator Breaux. I mean what is the total cost.
Dr. Barsley. In Louisiana, our budget for adult services is
about $4 million.
Senator Breaux. Four million dollars for dentures.
Dr. Barsley. For dentures only and the exams that go with
them, yes, Senator.
Senator Breaux. Suppose we just did not do dentures, and we
used the $4 million for oral health?
Dr. Barsley. That is what I am looking at.
Dr. Folse. Yes.
Senator Breaux. Is there any prohibition--I mean, could a
State do that if it wanted to?
Dr. Barsley. Senator, we could, but I am very much afraid--
in fact, we are discussing this very weekend adding dental care
for adult pregnant women to help decrease low birth-weight
children. We are estimating that adding extractions and
cleaning their teeth will probably cost about $3 to $4 million
for the 30,000 women who would be covered in the next year. So
if we were to cover all the Medicaid-eligible people in
Louisiana and cover a range of services limited just to that--
--
Senator Breaux. Does anybody know if any other States just
cover dentures?
Dr. Folse. That is optional. I mean, you can cover whatever
set of benefits you want.
Senator Breaux. Yes, I know, but I think it is unusual that
we cover dentures but not oral health.
Dr. Folse. Yes.
Dr. Dolan. Senator, the State of Florida had an adult
denture program until about 2 years ago, and when they had
Medicaid cuts, they eliminated that program. That is why my
State is a ``red'' State on Dr. Folse's chart, because
actually, we have one of the highest proportions of older
adults in the United States, and yet we do not have the ability
to serve the needs of those individuals.
Senator Breaux. So Florida is not able to do dentures or
anything else in oral health?
Dr. Dolan. No. In fact, I was the dental director for four
nursing facilities in Florida as part of my teaching
responsibilities at the University of Florida and was faced
with the same frustrations that you face every day in that you
try to do the right thing for these individuals, and yet there
was not the public or private financing to meet the needs of
the residents of these facilities.
Dr. Folse. Senator, I beg your forgiveness for the
interruption. You are talking about cost. In special care
dentistry, we looked at the problem of including oral health
for adults in Medicaid, and when you cover the whole
population, it costs a lot of money. You are really in a jam.
You are not able under Medicaid to carve out like ``aged,
blind, and disabled.''
If we could carve out ``aged, blind, and disabled,'' which
is the most vulnerable population, and cover them under
Medicaid, that is a doable thing. We put together as part of my
written testimony the proposal--we looked at what California
spent on ``aged, blind, and disabled''--and they have full
dental benefits there--and we extrapolated that out to the
country, and it looked like about $1.2 billion a year if you
put those patients under the dental programs that are currently
there. That is pretty much a max, because some of those
patients are already being treated, so the ones like California
would be included in that $1.2 billion, so we are already
spending that. It would probably add from our estimation about
$700 million a year to the country to treat ``aged, blind, and
disabled'' under Medicaid. It just makes sense.
Senator Breaux. Would you have to drop others--aren't
children included?
Dr. Folse. Children are covered now under Medicaid;
correct.
Senator Breaux. You are not talking about dropping them.
Dr. Folse. No. I am talking about just adding ABD adults
into the EPSDT program that is already existing in all the
States.
Senator Breaux. Does anybody have any thoughts about that?
Yes, Paul?
Dr. Glassman. Paul Glassman, from Special Care Dentistry.
Thank you for the opportunity to be here.
Greg is referring to some data that we did collect in
California, where the people who were in that category, adults
who are ``aged, blind, and disabled,'' account for 33 percent
of the Medicaid population in California and currently use
about 20 percent of the Medicaid dollars. So that is where the
numbers came from to extrapolate what it would cost nationally.
California actually received a C-plus on the chart, which was
one of the three highest States because of that program--
although that program has been threatened and almost went away
this year. Again, the one-time block grants to the States saved
it from being removed this year.
I also wanted to comment that--you asked earlier about
data--in the recent Surgeon General's Report on Oral Health in
America, it actually says in the report that one of the
problems when you are talking about special populations is that
there really is not any good data, and it actually talks about
that in the report.
I am president this year of Special Care Dentistry, and we
have 1,000 members, which is a small group of very dedicated
people who spend their lives treating people who are aged,
blind, and disabled, and each one of those people has a
thousand stories. So there is no question in our minds that
this is a huge problem. The numbers are staggering, but as Greg
says, it tends to be a silent epidemic because the people who
are suffering really do not have a voice to let their suffering
be known.
Senator Breaux. Tell me again what is your situation in
California. The aged, blind, and disabled constitute about 33
percent?
Dr. Glassman. We have an adult Medicaid program for
dentistry, so adult Medicaid recipients are covered by dental
benefits. Of those who are covered, about 25 percent fall into
the category of ``aged, blind, and disabled,'' and they use
about 20 percent of the Medicaid expenditures.
Senator Breaux. What does the program in California cover?
Dr. Glassman. I cover all the kinds of things that Dr.
Folse was talking about--basic examinations, cleanings,
fillings, extractions, treatment of infections, screening for
oral cancer. It does cover dentures. Some people say that it
does not cover enough, but I actually think it is a very good
program for basic services.
Senator Breaux. But how did they only get a C if they cover
all that?
Dr. Klaus. Because they missed in other major--I do not
have the report right in front of me, Senator--but they missed
in other major categories. Paul, you probably know those better
than I do.
Dr. Glassman. I think it is actually a good program
compared to many States in the country. It certainly has its
problems, and I think that is where the C came from.
Senator Breaux. So you miss seniors who are not aged or
disabled or blind; they are not covered?
Dr. Glassman. Yes, that is right. Low-income seniors are
covered.
Senator Breaux. All low-income seniors eligible for
Medicaid have dentistry as an option.
Dr. Glassman. Right, yes. Most people who are eligible for
Medicaid gets dental benefits, right.
Dr. Folse. Their low grade came from real low reimbursement
rates.
Senator Breaux. Other than that, they have a good program.
It is just a question of the reimbursement rates--because the
services are provided.
Dr. Folse. Yes. A lot of the States have full coverage is
what they say, but when you look at the effectiveness of that
coverage, because it is below the tenth percentile of what
dentists charge, it is real hard to get the infrastructure.
Senator Breaux. That is true of everything--in the CHIP
program in my State of Louisiana, we have insurance for
children under the Medicaid program, but the reimbursement rate
is so low that many doctors refuse to take children as patients
because of the reimbursement rate. It is all a question of
money, isn't it?
Dr. Folse. Yes.
Senator Breaux. Is there other discussion on this?
Yes?
Dr. Harrell. I wanted to bring up the reimbursement to make
sure you are clear. States have programs; it does not
necessarily mean they fund those at a reimbursement level
adequate enough for people to have access. In North Carolina,
by a funny twist, the State was just successfully sued by a
children's advocacy group because they did not raise the fees,
the reimbursement, enough to allow the required access. The
funny thing is--not funny--but the nice irony is that they did
it by codes, and a lot of those codes are also adult codes. So
that is going to help our geriatric Medicaid population also.
But just because you have children's Medicaid or a Medicaid
program does not necessarily mean you are providing access.
Senator Breaux. Let me understand. How many States have
dentistry covered under the Medicaid program, regardless of the
reimbursement rates?
Dr. Folse. Virtually all of them.
Senator Breaux. So all of them do--Louisiana, too? I
thought we just covered dentures.
Dr. Folse. There are I believe eight States with no
services at all, and this is from some data that I had about a
year ago, so I am doing it by memory. I think we had eight with
none and 22 with either limited or emergency only, and the rest
of the States had what they considered full coverage for
adults. For children, everyone is required to have full
coverage.
So the heart of this would be taking ``aged, blind, and
disabled'' and saying you must cover them also, and that is
where ageism comes in to me. We have a vulnerable child
population, and we have the same issues on a vulnerable adult
population, but we do not have the same requirements. I would
love to see that as a requirement.
We could increase the FMAP for the States, too, the Federal
matching dollars. If we increased that for that program, it
would be a really nice thing that would fly politically--with a
big question mark.
Senator Breaux. I'm not sure what flies politically today.
Dr. Davis, what about CMMS? Can you comment on what we have
been listening to here?
Mr. Davis. The latest number that I have on the number of
States that do provide adult dental care is 8 for full
benefits, 16 for limited benefits, 18 for emergency-only
benefits, and 9 that have no coverage at all. Those are the
current numbers right now on the Medicaid side.
Senator Breaux. Karen.
Ms. Sealander. Karen Sealander with the American Dental
Hygienists Association.
While there are many inevitable declines in seniors'
health, a decline in oral health is preventable, and that is
why it is such a tragedy to see Dr. Folse's slides; because if
seniors receive regular preventive services, we could prevent
all of these horrible oral health tragedies.
While the profession of dental hygiene was founded back in
1923 as a school-based profession, over the years, hygienists
have lost many outreach opportunities. One solution to the oral
health care crisis that ADHA would like to see is increased
entry points into the oral health care delivery system. Even
seniors who have insurance, whether it is Medicaid or private
insurance, often cannot get access to care because they cannot
travel to a dental office. So we need to go out and reach these
seniors where they are, and ADHA would like to see dental
hygienists play an increasingly important role in delivering
care to people where they are, whether that be in a nursing
home or an assisted living facility.
In many States, there are restrictive supervision
requirements, but there are some States pioneering less
restrictive requirements, and ADHA would like to see that
encouraged.
Presently 25 States allow hygienists to provide services in
nursing homes; 12 States recognize hygienists' ability to
provide services to homebound patients; and 10 States recognize
hygienists as Medicaid providers. ADHA would like to be part of
this solution in a collaborative way. Dental hygienists cannot
provide all oral health services--we need to work in
conjunction with dentists--but hygienists would like to be able
to reach more seniors with our services.
Senator Breaux. Let us talk a little bit about that. I do
not want to get into a battle between dentists and hygienists,
like we have done over the years with psychiatrists and
psychologists and chiropractors and medical doctors, et cetera,
et cetera. But there are two questions. No. 1, how much help
can dental hygienists provide if they were involved in
treatment of our elderly citizens, and No. 2, if they can be of
help, how many of them would be available considering the
shortage of dentists that we have?
Can anybody talk to me about how much help they could be?
Ms. Sealander. Senator Breaux, with respect to the historic
turf battle, there is more than enough unmet need for all of us
to play a significant role, so there is really no need to
squabble over turf.
With respect to the workforce issue, the number of dental
hygienists in the workforce has grown steadily and is expected
to increase by 37 percent between 2000 and 2010. Dentists, on
the other hand, are among the five health professionals with
the slowest rate of job growth, a 5.7 percent increase
projected between 2000 and 2010.
Right now, approximately 5,500 dental hygienists graduate
each year and about 4,300 dentists graduate each year. Morever,
dental hygienists are educated to care for geriatric patients;
geriatric care is a required part of the dental hygiene
accreditation standard.
Because dental hygienists provide preventive oral health
services; and do not provide restorative services, hygienists
to work in connection with dentists, and hygienists can serve
as a pipeline to dentists. One hygienist in Portland, OR
provides services in a nursing home in an onsite dental clinic
that was built with donated equipment. She works there one day
a week, and then, one day a month, a dentist comes in and
provides the needed restorative care.
Dr. Folse. They would be an integral part of the team, and
I think hygienists are going to be integral in the final
solution of this; they are going to be a big part of it.
Senator Breaux. Anybody else?
Paul, and then Jim.
Dr. Glassman. You are touching now on workforce issues,
which I think are going to become a major problem. This problem
that we are talking about now with elderly and disabled people
having difficulty getting access to care is going to get worse
because of workforce problems.
It certainly is true that the number of hygienists is
growing faster than the number of dentists. Dentists who are
retiring now went to school at a time when there were 6,000
dentists a year being produced, and they are being replaced by
today's 4,000 graduates.
The thing I want to point out, though, is in all of the
estimates about how critical this workforce shortage is going
to be, all those estimates if you look at them carefully are
based on an underlying assumption, and that assumption is that
those people who are currently left out of the oral health
system who do not have access to oral health are going to
continue not to have access to oral health. All the analyses on
workforce are based on that assumption
Senator Breaux. Dr. Harrell.
Dr. Harrell. The American Dental Association has
consistently studied the workforce issue, and there are some
problems with some of the data, and it is hard to project the
needs in the future. We recognize the value of hygienists,
particularly as Greg said in a team concept, where the dentist
does the diagnosis but the hygienists particularly are
extremely valuable, I think, on the education end of this
thing.
I looked the other day, and there are 44 States--our policy
in the American Dental Association is that it is sort of a
States' issue, but 44 States have chosen to give some laxity of
supervision to hygienists in nursing homes. Whether that has
increased the care, I do not know. The only concern is that the
diagnosis is done so that we do not just polish decay but that
we really give treatment.
Senator Breaux. Yes. It seems to me that some of these
people who are institutionalized, not to mention those who are
not in institutions, but all those who are in assisted living
facilities or nursing homes, never really have anyone look into
their mouths to see what kind of oral health they have. A
dental hygienist could certainly help identify serious problems
that necessitate a dentist to do the extra work that may be
required, but there is an awful lot that could be done just to
help identify the problem and help with at least a partial
solution to the problem.
Dr. Collins.
Dr. Collins. Thanks, Senator.
Like others, I appreciate the opportunity to be here. For
the moment, I would like to make three points.
One is about the reimbursement issue, which is obviously a
complex one, and you have heard a lot of different statistics
about what is covered and what is not covered. The key issue to
me is that the service is an optional one regardless of where
you are in the United States, so that when times get tough,
things that are optional tend to disappear. This is the
solution that Greg is offering as an attempt to address that.
The second point I want to make is about education and
training, looking at alternate solutions--not necessarily
training an entire workforce of geriatric specialists--that is
probably very impractical, although I would certainly encourage
us to have a core of them; certainly we need them as faculty to
teach, we need them in programs where they can take referrals
for the more difficult, and we need them to educate of general
dentists in order to get treatment to these older patients, who
yes, may have the same kind of disease, as younger patients but
they also have many co-morbid conditions that make it difficult
to treat them and that add special conditions that require
consideration.
In some of the material that was provided in advance of the
hearing, it has been reported the dental schools, that have
made considerable progress in offering didactic material--in
geriatrics nearly all of them do now--but clinical training has
lagged behind.
I graduated from dental school in Philadelphia in 1971, and
there was no geriatrics in my course of study; there was very
little public health. Downstairs in a little, obscur room,
there was something called a special patients' clinic, and I
had an instructor who by chance got me involved in that clinic,
and I think it made a big difference in my interest in this
area and in public health in general, because you got an
opportunity to understand that these people had needs like
everybody else, and they were eminently treatable if you had
the right skills and you understood that.
So that is definitely one of the three legs of the stool.
You have to have practitioners who understand that whether they
are dentists, whether they are auxiliaries, whether they are
hygienists.
The third point I want to make is in the area of research.
In the Surgeon General's Report, he talks about science being
the lead and the connection for us to make progress in this
area and many other areas in oral health. I definitely think
there are many opportunities, some of them linking the
reimbursement and workforce issues, maybe done through the
universities, looking at different distributions of personnel
and how well they can address problems, whether the elderly
patients are in the community or they are in the institutional
setting, because in either situation, it is not a matter of one
size fits all. We used to make assumptions--and I think that is
why there are so many denture programs or priority on
dentures--that people were going to lose their teeth, and if
they lost all of their teeth, then they were going to need
dentures. Our other priority was kids. So we had denture
programs, and we had basic programs for kids.
Times have changed rapidly as dental insurance has grown.
We have people with complex medical problems, but they also
have complex dental problems; they are moving into old age, and
suddenly, they do not have reimbursement for this care, and as
they develop other kinds of co-morbid conditions, they have
problems.
There is a vast opportunity for us, I think, in the
research arena, delivering care in many cases at the same time,
to find solutions that use resources wisely--give patients what
they need; do not give them more than what they need.
Senator Breaux. A good point.
Paula.
Dr. Friedman. Thank you, Senator.
I wanted to point out a workforce issue agenda that is
actually interdisciplinary, and it speaks to the need for
increased education in oral health across all health care
disciplines, and the invisibility, if you will, of oral health
care among other health care providers.
I brought with me for the purposes of this hearing two
publications that just came out. One is a Public Policy and
Aging Report produced and published by the Gerontological
Society of America called ``Emerging Crisis: The Geriatric Care
Workforce,'' which speaks about the dearth of health care
providers across all health care professions, except that oral
health is not even mentioned here. There is no mention of oral
health in this well-respected association's publication on the
workforce crisis.
The second one is a joint publication by the Merck
Institute of Aging and Health, and again, the Gerontological
Society of America, called ``The State of Aging and Health in
America,'' which again does not mention oral health at all.
So I think that when we talk about workforce issues and
about increasing awareness of oral health as an important and
critical component of overall health, which was mentioned by
Surgeon Everett Koop many years ago, it is very important to
not only consider the oral health professions but
interdisciplinary professions as well.
Senator Breaux. That raises a question, Greg, with your
slides, and I am sure that any State you go to, you could go to
a senior facility and see the same problem, maybe some even
worse certainly, maybe some not as bad. But why doesn't a
regular medical doctor when doing a normal check on an elderly
American--anybody can look into someone's mouth and say look,
they have a dental problem. I mean, I could look in there and
say this is a dental problem before it got to the point where
it got there. You did not need a dentist to tell those folks in
your slides that they had a problem long before it got to that
point.
Do doctors not notice this, or ignore it, or just do not
look?
Dr. Folse. I have had a lot of interaction with the
American Medical Directors' Association. They are the doctors
who go into the nursing homes. I teach them about this, and I
called it ``the forehead slap''--when you talk about it and
they go, ``Oh, my God--I am not even looking.'' I see that time
and time again. I call it ``the forehead slap factor,'' and I
have it on an additional slide.
We have a long way to go in that regard. I think, though,
that as we gear up as I have in my area and as other dentists
have around the country, when you gear up an oral health
program, they start thinking about it. Then, when you have a
few patients who have complex problems and you point it out to
them, they start looking. But it needs to be part of the normal
routine, and it is not right now.
Senator Breaux. Teresa.
Dr. Dolan. Senator, I had the good fortune as a recent
dental graduate to participate in a VA fellowship training
program which was multidisciplinary, where I worked with the
nurses and physicians and physical and occupational therapists,
and we learned from each other. That was one way of sensitizing
them to oral health issues that they were probably never
exposed to during their usual curricula.
Also in the VA, they had dental operatorie in the nursing
facility, and we provided preventive and restorative care with
dental hygienists, and it was a wonderful model.
Over time, those programs disappeared, so we had probably
fewer than 30 trained geriatric dentists who had that
experience.
Senator Breaux. In VA facilities?
Dr. Dolan. In VA facilities. Many of those VA trainees are
in this room and have become the academic leaders in geriatric
dentistry.
When I joined the University of Florida, we had a 6-year
HRSA training program, also multidisciplinary, with physicians,
dentists, and other health care providers, where we learned
from each other. Physicians learned about oral health. We
learned from physicians about medical complications that were
important in dental therapy. Again, those programs were
severely cut in Federal budget cuts. I believe that now there
are fewer than 10 individuals being trained in those programs.
We no longer have a program in the State of Florida.
I think models have been tried and have been successful,
but they require commitment and resources. I think we do have a
lot to learn from each other. If you look at the medical
education curriculum right now, there are probably less than 10
total hours of instruction, in a good school, about oral health
issues.
So I think there are many, many areas that need to be
addressed. We have had models in the past that have worked and
for one reason or another are no longer funded and supported.
Senator Breaux. Yes, Dr. Musher.
Dr. Musher. Senator, I am a physician. I am board-certified
in family practice, and I am a fellowship-trained geriatrician.
I am also a past president of the American Medical Directors'
Association, so I was happy to hear comment about that.
One of the things that that organization has been trying to
do is help educate our medical directors who by law have to be
in nursing homes related to the different issues that are
important in nursing homes, and one of them is oral care.
But I do want to mention in my training as a fellow that I
was trained in oral care. I reach a point, just as anyone else,
where I would find a problem in oral care and I would need to
find a dentist or an oral surgeon to help care for that
problem.
But I think we are saying two important things here. One is
the team approach, and the second part is education. In the
nursing homes, we have what is called the minimum dataset, and
in part of that, we are supposed to be assessing for oral care
and looking in our residents' mouths, our patients' mouths, and
assessing for certain problems.
I have heard a lot of people have advocate for education,
and I think that is critical. I think we have to better educate
the staff in the nursing homes all the way down to the CNA
level what to look for and then how to plug that patient into
the system, and I think they can be educated. They are with the
patients every day. They are helping brush their teeth, taking
care of their dentures, et cetera, et cetera, so I think that
would be important.
I think educating physicians to work with dentists and
other health professionals is part of that. I think there are a
lot of physicians who are still in nursing homes that are not
as well-trained or feel as comfortable, if you will, looking in
patients mouths.
I also wanted to comment that, for example, a lot of the
patients we are seeing now in the nursing homes are frail, they
are demented, they are a little harder to care for in some of
these ways, but there are some simple things besides what we
have heard today that I struggle with every day such as
xerostomia, which is just a dry mouth, either from medicines or
just from the aging process, which has huge repercussions. I
have had patients who were going to get gastric feeding tubes
because they stopped eating because you need saliva to taste
the food. My patients were not tasting the food, and they
stopped eating. As soon as that was brought to my attention, I
realized it was a dry mouth.
That is something simple that anybody could hopefully
recognize and correct. So I think it underlines again that more
education is critical.
I guess one side comment because I also have a private
practice, and one of the things that has frustrated me--and
maybe it gets to the financial issue a little bit--is that I
think if there were less paperwork related to billing issues,
maybe the health care system would not be as costly.
Senator Breaux. Thanks, Jonathan.
Robert.
Dr. Klaus. It seems to me and to Oral Health America that
there are two chapters in health history in the United States.
One is overall health, and then there is oral health. This has
contributed to the problems of oral health being perceived in
almost abject isolation and what we call almost a militant
indifference--and it is not just us. Listen to how the
Frameworks Institute, a think tank in Washington, DC.,
describes the problem.
``You cannot solve a problem that is not perceived to exist
by the public. To say that this issue has not emerged in public
discourse is to greatly understate the issue. It is
invisible.'' I would suggest just looking around the room--and
I do not know everybody here--but we are all part of the oral
health family, and the solutions to this problem will not be
advanced, Senator, until we begin to get outside and get
coalitions that speak to this issue as passionately as we do.
Senator Breaux. That is a good point. I have always said
that in solving problems, first, people have to understand that
there is a problem, and after you realize there is a problem,
you can talk about possible solutions to the problem. The third
part of any program is to convince people that these solutions
are worth pursuing and worth investing a financial commitment
to help pay for what you think is the right solution.
So first, you have got to recognize that there is a
problem, and that is what we are trying to do and to try to let
more people know that the oral health of our Nation's seniors
is a severe problem and is one that can be corrected.
Then, we have got to come up with some ideas of what should
we be doing. Greg suggested trying to make sure we at least
cover aged, blind, and disabled seniors. We could start in that
area.
Then, you have got to have the political wherewithal to go
out and sell that proposal.
So it is a three-step process. It is not rocket science,
but it takes some commitment on the part of people.
Somebody else had a point. Paul, first.
Dr. Glassman. Just to extend this discussion about
awareness and are people seeing things or not seeing them or
ignoring them, I think it is a combination of both. It
certainly is a gigantic awareness problem where people look
right past the mouth and sometimes do extensive medical tests,
workups running to thousands of dollars for somebody and it
turns out to be a dental problem.
I spent 20 years working in a hospital dental clinic where
that would happen time and time again. You would have someone
who was in the ICU and had been there for a week and had had
all kinds of expensive tests and then finally, in frustration,
giving up and saying, ``Let us call a dentist in,'' and you
would look, and sure enough, there would be a dental infection,
and that was what was causing the problem.
I supplied a videotape to your staff of an adult lady who
was not verbal and mentally retarded who was admitted to a
locked psychiatric facility in California at a cost of $150,000
a year to the State of California because she was exhibit
bizarre behaviors and lashing out at people around here.
Luckily, there was a dental hygienist in our State who was
connected through a program we have who came in and saw her and
thought maybe this was a dental problem. Because we have adult
benefits in California for this group, they were able to see
her, and within 24 hours after dental treatment, she was back
to her normal behavior and back living in the community again.
That was a pretty dramatic story. So I think we have a
giant awareness problem, but I think we also have a giant
frustration problem, which is imagine that you are a physician
or a social worker or a nurse and you are in a nursing home or
working with a group of disabled people, and you look in the
mouth and you recognize there is something wrong, and you try
to get someone to come in and see that person. How many times
are you going to try? You dial the phone, and you call 20
dentists, and after a while, you give up, and you stop looking,
and you stop trying to even bother because you know you are not
going to get anyone to come in and see them.
So we need awareness, and when someone does become aware,
we need to have something that they can do that is going to
work.
Senator Breaux. That is a very dramatic story from a cost
standpoint.
Dr. Harrell. Senator, we appreciate you taking your time
this afternoon, by the way.
I want to make two points. I just participated in an
Interfaces Conference which dealt with children's dentistry,
sponsored by the American Association of Pediatric Dentistry,
and they had a group similar to this. The physicians in the
group did state pretty overwhelmingly that--I think they would
have caught some of the slides that Greg had--but especially a
lot of the subtleties of oral health, they were not trained in.
In fact, none of the doctors present were. I thought that was
interesting.
Second, with Dr. Folse and some of the people who are
sitting here, we are developing an oral health assessment and
survey process for nursing homes, and CMS is reviewing that
right now. Basically, we would like to at least have the right
questions asked, hoping to raise awareness on oral health
needs.
Senator Breaux. Tell me about what. What are you all
submitting?
Dr. Harrell. It is called an oral health assessment and
survey. It is for nursing home patients, and the nursing home
fills it out. That is being produced right now; CMS I think is
reviewing it.
Senator Breaux. Do they do that now, or not? Is it a
requirement to do that now when a patient enters into a nursing
home?
Dr. Folse. Yes, yes. In every nursing home chart, there is
a health questionnaire called the MDS, and on the MDS are seven
different oral health questions, and those questions have a lot
of problems.
Senator Breaux, you have been instrumental, whether you
know it or not, in helping me to expose that at CMS. It was
from some of the letters and correspondence that you had with
CMS about oral health a few years back; so I had it down to
thank you for that, actually.
We have submitted the actual new questions that will be in
every chart across the country, which are going to be good
questions.
Senator Breaux. How do they differ from what the existing
program requires?
Dr. Folse. The existing questions had the four main
diseases--oral cancer, tooth-borne gum disease, and
prosthetics--all mixed into a bunch of jumbled questions, so
when you tried to answer one, you had to look at three
different things.
We separated out those four areas, and by separating them,
we will be able to use some of the national data that we have
about cavities and gum disease for the gum disease questions.
Also, again because of your efforts at CMS, we did the
National Surveyor Training Session about a year and a half ago,
where we trained the nursing home inspectors. It was pretty
much based on the MDS, and the video from that has been
dispersed--there were a lot of responses from our facilities
across the country looking at oral health. They got this
videotape, and they looked at it because they wanted to know
what the surveyors were going to be looking for.
We are still pretty deeply involved in it, and special care
dentistry has really been teaming up with ADA and CMS to have a
real good result with that.
Senator Breaux. Can Mr. Davis comment on that? That survey
will indicate the potential problem that senior has coming into
a nursing home.
Dr. Folse. Correct.
Senator Breaux. It does not provide any treatment, but it
at least recognizes that there is a problem.
Dr. Folse. Correct.
Senator Breaux. Can you comment on the use of that data?
Mr. Davis. That data is collected on each patient, and it
is actually collected in the nursing homes. It is expanded now.
Dr. Folse spoke recently to a group that CMS participated in.
It is a contracting group, and they are looking at this
expansion of questions for a minimum dataset for dentistry.
That is still under review. It is not finalized yet. But it is
an expansion.
Senator Breaux. That does not do anything for the patient.
It is just sort of let us go to the wreck site and see how many
people are hurt.
Dr. Folse. Correct.
Mr. Davis. Right. Surveyors used that as a part of their
review. It is part of the things that they look at. They do
look at medical records, and they do have interviews with the
patients and with the families and with the staff, and they do
have observation.
Senator Breaux. Where does that MDS go?
Dr. Folse. If somebody has a cavity--the new question says,
``Does the resident have a cavity?'' If they check ``Yes,''
that goes onto the care plan. Once it is on the care plan, they
are supposed to refer that patient to a dentist or get
appropriate care.
That is actually the way that it is supposed to happen now.
The problem has been in the actual assessments. We have not had
enough training to get those done correctly, and where I found
40 percent of my patients had a ``Yes'' trigger to the gum
disease question, we found across the country out of 3.6
million MDS's 0.8 percent that were being triggered. So we were
missing 39.2 percent of the population, according to my
records.
Once that got exposed to CMS, they did make a commitment to
us and to you to get the new questions and also to put in a
quality indicator for oral health, which means not only will
that information be used at the nursing home level; they
receive all of those data electronically, and if an individual
facility would have, say, greater than 60 percent gum disease,
or they would report less than 20 percent gum disease, it would
trigger the quality indicator for oral health, which would let
the surveyors inspect specifically for oral health issues.
Right now, the MDS questions are not tied to a quality
indicator, so you can check them all of or you can check none
of them off, and no survey question will come because of the
MDS questions. So we are changing that.
Senator Breaux. My next question was who makes that
assessment. When you are admitting someone into a nursing home,
is it a registered nurse, a practical nurse? Is it just an
administrator who is on duty that night, who takes a look at
the patient and says ``Yes'' or ``No''?
Dr. Folse. In my facility, it is a range. Some facilities
have licensed practical nurses do it; some have RN's do it. I
have one facility--I do not go there anymore--where the social
director was doing it, which was not that appropriate.
Having the training to get them up-to-speed will help. I
think the way that we handled that broad case was ``This is
normal'' and ``This is abnormal.'' If it is abnormal, you check
it, and you refer it. We tried to make it real simple, get out
the big dental terms--that is not going to work.
The problem with the personnel who are doing it now is that
every time they check this stuff off, they have to refer, and
there is no infrastructure to refer them to. So it is a round-
robin thing.
Senator Breaux. Dr. Musher?
Mr. Musher. Yes, just a couple of comments. One, I can
assure you that the MDS is taken very seriously in the nursing
home, but I think it is more of the stick than the carrot is
what you are hearing, and it is also data. I think what
everybody is saying--and usually in facilities, it is an LPN,
licensed practical nurse, not usually RN level, who is filling
out this information--it is supposed to point out where we have
concerns or problems to then lead into other things. It used to
lead into what we called the RAPs, which were resident
assessment protocols, or guidelines or other things--in other
words, there may be a problem, how do we now approach that.
I think that is good, but I think what everybody is saying
is that if it just becomes filling out the form and moving on,
then we really have not accomplished what we need to
accomplish. What we need to do is use that form as a guide, if
you will, or a screen to say that we may have some problems,
but we need to give the individual, whether it is the nurse or
the other individuals in the facility, the education and the
means to then go to the next step--because normally, as you are
pointing out--and I have been pretty fortunate in most of my
facilities to have dentists and dentistry available--but if
there is a problem, I usually get the call. You are absolutely
right--sometimes it is very frustrating to sit there and say
well, I think there may be an abscess or a problem, I know the
best treatment for an abscess is to take care of it, not just
to treat with antibiotics--how do we then get to the next step?
Dr. Folse. I actually as the dental director in my
facilities do the MDS for them, and that is one reason why I
really like the dental director model, because I am part of
that process, I am part of the team.
Senator Breaux. Yes, Daniel?
Mr. Perry. Thank you, Senator.
On one level, obviously, what we are talking about is the
deplorable state of oral health in America, especially for our
seniors. But just beneath the surface are two threads that are
coming together. One is the thread of ageism which is endemic
throughout the American health care system at all levels, where
older patients tend to get fewer preventive treatments, less
screening, fewer interventions than younger people would; and
on the other end--and this, too, is part of ageism in our
health care--is the failure of our professional health
education schools to be able to provide some access to
geriatric content for everyone who passes through them.
For those on the committee who may not know it, Senator
Breaux has taken the leadership on both of these, and you and
your staff are to be commended for full-scale hearings within
the last 18 months, both on the shortage of academic training
in geriatrics and on ageism.
I cannot offer today a simple solution to ageism, because
it is part of our society; it is part of the fabric of who we
are, and it has terrible effects on older people in health
care. We ought to bring attention to it as you have been doing,
Senator.
On the issue of greater envelopment of health professionals
in their training in geriatrics, we can do something about
that, and I am urging you and your staff to look at what we
might do through HRSA to improve professional health education
with geriatric content and most promising to create some
department-level centers in our academic health centers where
not only physicians and nurses and pharmacists, but dentists
and all allied health professions, have to rotate and receive
some of the basics in good geriatric care before they are out
treating a patient population that increasingly is 50 percent
age 60 and older in this country.
Senator Breaux. I think that is a helpful suggestion, and I
think we have heard a number of them. I am trying to figure
out, if you had the ability to write a recommendation to the
Congress and to the U.S. Senate as to how we can improve the
quality of dental care for our Nation's elderly. I have heard
the suggestion of the greater use of dental hygienists because
of the shortage of dentists in many areas. I have heard the
suggestion of trying to increase Medicaid coverage for the
aged, blind, and disabled, at least move in that area with a
limited amount of money.
Are there other suggestions that may be appropriate that we
have not put down?
Paula.
Dr. Friedman. Thank you, Senator.
I have four recommendations that, with your permission, I
would like to read into the record.
``One, broaden grantee eligibility for geriatric training
programs. Dental education institutions currently may only
compete for geriatric education center grants. ADEA recommends
that grantee criteria be revised to include dental education
institutions as the responsible applicant for the geriatric
training for physicians, dentists, and behavioral/mental health
professionals program. We further recommend that the criteria
be broadened so that faculty members employed by U.S. dental
schools are eligible to compete for geriatric academic career
awards, which are currently limited only to physicians.'' While
I certainly agree that we do not need to train a huge cohort of
specialists, as you indicated earlier, we need to train enough
to, as we call it, train the trainers, so that they can train
general dentists and dental students.
``No. 2, authorize a new geriatric dentistry residency
training program. ADEA recommends that a new Federal grant
program modeled on the general and pediatric dentistry
residency programs be authorized by Congress to prepare the
dental workforce to meet the growing needs of an aging
population.'' This might be a component of an existing general
dentistry training program or indeed a second year added onto a
1-year training program in general dentistry with emphasis on
geriatrics.
``No. 3, authorize a new NIH loan repayment program for
research on the elderly and other special needs populations.''
I think that is self-explanatory.
``No. 4 and finally''--I believe this fourth one
encompasses both an access issue and the fiscal piece that we
all agree is an important component of geriatric oral health
care, and that is ``authorize a new reimbursement program for
elderly dental care at academic dental institutions. Dental
schools and their satellite clinics provide a significant
amount of oral health care to the elderly. We are considered
the safety net for people with limited fiscal resources. We
cannot expand services beyond what is being done if Federal
assistance is not made available to assist in paying for
unreimbursed care.''
Dr. Folse talked about the large degree that all dental
schools certainly are providing in terms of unreimbursed care.
``ADEA urges Congress to authorize a dental reimbursement
program for poor elderly obtaining treatment at the Nation's
dental education institutions.''
That certainly could include dental hygiene institutions.
For your information, Senator--I imagine you know this, but
just for the record--the fees at dental schools are generally a
fraction of fees in private offices, so that a relationship
with a dental education institution would be by extension a
fraction of the cost of a private practice program.
Senator Breaux. Those are good suggestions, and we would
like to make sure we get a copy of that and the whole
presentation.
Paul.
Dr. Glassman. I think that in addition to funding and
training systems, there needs to be a support system, and let
me tell you what I mean by that.
We are just finishing up now a grant program that we have
had in California. We have been working in eight communities
around the State where we have had what we call a community-
based system that is involved using people that we call dental
coordinators. They are mostly dental hygienists, actually, who
have played this role. Their role is to actually act as a
liaison between the social support agencies that exist in every
community that deal with the special populations we are
interested in and the dental professionals.
They do screening and triage; they get people into dental
offices; they entice dentists to be willing to say ``Yes'' when
they get a referral. They do preventive education.
I will give you an example of how it might work. Let us say
you are a dentist, and you have a busy practice, and your
practice is pretty full with people who can come in and pay
full fare and sit in your chair and do not have a lot of
complicated medical problems. So someone calls and says, ``My
mother has dementia. Can I bring her in to see you?''
You think, well, things are kind of busy, but sure, I want
to do my part. So the person shows up, and you find that the
daughter who brings the person in does not really know about
their medical history or the medications they are taking, and
their behavior is such that there is just no way you are going
to treat them, and you spend a frustrating half an hour or 45
minutes trying.
The next time you get a call like that, what do you think
you are going to say? You are going to say, ``No, I really
cannot do that.''
Now picture situation No. 2. You have a dental coordinator
in the community who calls up and says, ``I have just done a
screening on this individual. I was out to see them. I know
your office because I have talked with you before, and I know
the kinds of things that you are able to do in your office, and
I think this person would work pretty well in your office. When
they get there, I am going to make sure that you have all the
medical history information you need, and we are going to take
care of the consent issues, because I am going to work with the
social service agency who knows how to get consent.''
When the person gets there, they are going to have the
medical history, the consent is going to be taken care of, they
are going to be matched to the dental office. Now, the chances
of that referral being successful are infinitely better than
the first one.
So in that kind of program, our 3-year results are now
showing that people have significantly less dental disease.
There are numbers of dentists in these communities who are now
willing to say yes under the circumstances I just described who
were not willing to say yes before. In fact, the amount of
dental disease in the population we are talking about, the
burden of dental disease, the cost of providing treatment for
that dental disease has gone down to a degree that it is more
than the salaries that we are paying to these dental hygienists
who are providing these services.
So I think there needs to be a support system that goes
along with funding and training.
Senator Breaux. So your suggestion is--are you trying to do
this in California, or----
Dr. Glassman. We are just finishing up a 3-year
demonstration and demonstrating the effects of this, and we are
showing great results.
Senator Breaux. So is there a dental coordinator for
seniors?
Dr. Glassman. We picked eight communities throughout the
State. We have a dental coordinator who works with social
service agencies in those communities and plays this role of
acting as a liaison between these agencies and the dental
community, helps to bridge the gap, helps to make the kinds of
referrals that we talked about, does preventive education and
preventive programs, does screenings and gets people into care.
Senator Breaux. A good idea.
Jim.
Dr. Harrell. The only thing that would worry me is that in
North Carolina, we have a shortage of dental hygienists, so I
cannot tell you where you are going to get them--do not take
them from my office.
Also on the manpower issue, as I said, we have studied
that, and the term ``shortage'' has been used a couple of
times. I do not know--and there again, the data is kind of
squirrely--but I do not know that we have a shortage, but we
definitely have a maldistribution.
I think the Surgeon General mentioned diversity of the
dental work force. The University of North Carolina is starting
to give preference to students from rural areas, hoping that
they will return to rural areas when they graduate, because
they tend to go to the metropolitan areas. So it is hard to
know, but I do not know that we definitely have a shortage.
Senator Breaux. We have had some good suggestions, and this
is the first thing that we have ever focused on a particular
problem area of seniors in terms of a disease. We have held
hearing on senior problems with people who were scamming them
from an insurance standpoint, people who discriminate against
them in the job market, actual care and treatment that they get
in nursing homes, and have looked at alternative means of
caring for seniors. But I think this is really the first time
we have actually had a discussion on a particular ailment of
seniors that has not been noticed as much as it should or
treated as adequately as it could be. I think it has been very
helpful to do this, because this really is sort of a silent
illness out there that people are ignoring, and it leads to
much more serious problems, much more expensive problems, and a
lot of suffering that in many cases is unnecessary in today's
society.
The question is how do we go about trying to fix it and how
do we go about trying to solve it. We have gotten some good
suggestions on the table, and I would like to see if anybody
has any closing comments, perhaps, to help us summarize.
I want to try to bring the information we get from here to
maybe do some statements on the floor of the Senate to try to
get some other Members interested in this, because when you
find out that most States are not doing a very good job of
paying attention to the oral health of our Nation's seniors
within their States, it is a serious problem, and it should not
go neglected as we have neglected it in the past.
Does anybody have any final suggestions that may be
helpful?
Robert.
Dr. Collins. Thanks, Senator.
This has been a wonderful hearing. There is an awful lot of
information that is out there, and many people around this
table and others have had an opportunity to contribute to that.
I think this is one more step in the Surgeon General's Call to
Action booklet which he kind of modestly talked about today,
but I think is increasing the involvement of a larger community
of people.
I had a mentor as I came along in public health who used to
talk about ERAs of expectation in regard to oral health. The
first one, which I guess covers a large portion of history, was
resignation. You had pain, and you just found out a way to deal
with it, and maybe you had somebody who could relieve it by
knocking your tooth out.
We went into a second period of rehabilitation where you
had dentures available, crude in the beginning, more
sophisticated as time went on, where people could still expect
to lose all their teeth, but now they had some sort of
replacement.
The third era, which we are really still in and coming out
of as a whole is the restorative area. These are the 77 million
that you are talking about in your question, people who have a
lot of complex dentistry who are moving into older age.
The final era is one of prevention.
So, we have some conflicts here with people who are in an
era where they are beginning to expect that a lot of these
problems that Dr. Folse so nicely illustrated today should not
be there--they should be prevented. We have research that can
go a long way toward pointing the way to do that, yet we have a
system that I would say in many cases is not even in
rehabilitation in terms of responding; it is back in
resignation.
So there are lots of ways that we can point forward to the
future, and I just wanted to underscore my appreciation and
support not only for what the Surgeon General is doing, because
I think that is a terrific, terrific booklet, that little green
booklet, but also for all the Federal agencies, in particular
the National Institute of Dental and Cranio-Facial Research--
yes, it does support a lot of research in universities and
across the country and funds most of the dental research and is
therefore very important, but it also serves as probably the
principal coordinating center in the Federal infrastructure for
oral health and makes it possible, I would say, probably if you
go back to the beginning, possible for all of us to be here
today.
Thank you.
Senator Breaux. Thank you.
Ms. Heinrich, do you have anything from General Accounting?
Ms. Heinrich. I really do appreciate the opportunity to
hear all of these ideas. It really is very thought-provoking.
I appreciate your point that there are several ways of
focusing on this problem, and one question I had was with the
focus that we have put on prevention with children--
fluoridation, for example--do we anticipate that this problem
is going to wane in the future?
A second question--Paul, you have talked about some best
practices in California; there might be some in New York also,
since they got a C-plus--but has there been any effort to
identify strategies that really do work in trying to bring
better dental care to older populations?
Senator Breaux. Let me interrupt. I am going to have to
take off. But Janet, why don't you all finish up on this
question, and let me just conclude for my part and thank each
and every one of you. I think it has been very important, and
we have gotten some good ideas.
To those who have travelled, thank you, Greg and others who
have come from other places, for being with us. It was well
worth your effort as far as I am concerned. I am very
appreciative of the information that we have been able to learn
and the suggestions that we have received.
So I thank you all, and please continue.
Dr. Folse. Before you leave, we thank you very much.
[Applause.]
Dr. Glassman. Just to respond to the question about best
practices, yes, I think there are a number of publications and
articles and lots of information about best practices. The
problem is that the best practices, the theoretical ones, the
ones that have been used in demonstration projects, are not
widely available and not widely used because of the issues we
have already identified here--awareness and funding and
training.
So the best practices do exist. The American Association of
Geriatric Dentists has a number of publications about
guidelines for nursing home dental practice. There are
guidelines in other areas. The next issue of the Journal of
Special Care Dentistry is going to have the results of an
expert panel that we brought together to look at prevention in
disabled and elderly populations.
So I think the information is there. The problem is taking
that information and translating it and getting it into
practice is where there is a gigantic chasm.
Ms. Heinrich. In terms of Senator Breaux' interest in
having material that people could speak to, are there some of
those that would have information about dollar savings or costs
that could be provided to Members of Congress?
Dr. Glassman. I am not aware of that. I do not know if
others are.
Dr. Collins. I pointed out earlier that one of the things
in the Surgeon General's report on Oral Health in America is
that it states in that report the lack of data about both the
oral health burden and strategies and all those things, and we
all wish we had numbers about those kinds of things. The
numbers are generally not available, unfortunately.
Dr. Folse. Dr. Barsley actually did a study in Louisiana
for Medicaid children where they used some interventions, and
there were significant savings with just water fluoridation for
that population.
Dr. Barsley.
Dr. Barsley. For children with fluoridation, we showed the
parishes or counties that were fluoridated had significant
savings over the counties that were not. Does that translate to
the adult population? I am not sure.
I would break in and answer one question--I do not see this
problem waning at all. As people have better teeth and better
lives, we are going to have a bigger problem. So I do not see
any waning of the problem in any way at all; it will just
continue to grow.
Ms. Heinrich. Paul, and then James.
Dr. Glassman. I just want to emphasize that point, that the
problem is not going away. We have gone from in our country 20
years ago, I think it was something like 56 percent of people
over 65 being in dentures; now it is down to about 26 and
dropping. So we are having more and more seniors who are
becoming seniors with teeth that did not used to have that, and
the fact that disease for certain groups of children is going
away does not really have much impact on what happens when
people get to be 65 and can no longer care for themselves the
way they used to and begin to take medications and have dry
mouth. So I think this is going to be a blossoming problem.
Ms. Heinrich. Teresa.
Dr. Dolan. I would just add that I certainly agree that
this problem will not go away. It is a good news/bad news
story, because as the younger cohorts of adults age, and we
have retained their natural teeth--maybe we have had some
dental fillings--but we also have higher expectations, and we
are more vocal about our expectations, I think as those folks
become chronically ill and perhaps end up in long-term care
facilities, the demand for a more appropriate level of oral
health services will grow, and if anything, the cost associated
with that will increase. I think that what is currently a
silent epidemic will become more prominent.
Ms. Heinrich. Go ahead, James.
Dr. Harrell. As we have a unique program in North Carolina,
I will try to get any data on cost-sharing that the ADA has for
you. I am not sure what we have.
We do have an interesting program in North Carolina where
we have physicians apply fluoride varnishes. We are doing
studies on that, and I do not know the results at this point or
whether that will be a cost saving or not; we suspect that it
will. The problem was that by the time these children were
seeing a dentist at 2 or 3 years of age, they already had
decay.
The American Dental Association has been sort of reeling
with the punches and doing what we can to boost the Medicaid
reimbursements or whatever. We are having a Medicaid symposium
in December, which will hopefully be a small group similar to
this one, to actually look at the whole system and maybe come
up with some innovations for that system.
Also, thinking about Paul's remarks, we have a van program
which is mostly a nonprofit organization in North Carolina, but
I do not want us to overlook the fact that there are multi-
millionaires in nursing homes who cannot get care because they
have special needs, and they require treatment that they do not
have the facilities to do--even if they can bring them to my
office, I cannot do it. So I do not want us to overlook that
segment of the population either.
Ms. Heinrich. Senator Breaux was beginning to ask all of
you for recommendations on solutions to this problem, and not
all of you had a chance to speak, so I would ask if there are
other ideas.
Mr. Musher. Just a couple of points--I guess some things
that we could do now, not to lighten the big, 10,000-foot
view--but there are certain initiatives going on now. For
example, there is a pain initiative. There is a collaborative
initiative that CMS is part of concerning pain and trying to
develop best practices. Certainly oral pain problems and
syndromes could be better focused on through that.
So I think there are certain programs that are going on.
The American Medical Directors' Association has created many
guidelines. That could certainly be something that would lend
itself toward a guideline on how do you approach oral care in
the nursing home.
Again, not lightening the access to care, which is what I
hear is a huge issue, and my frustration, as I mentioned
earlier, is trying to get a dentist or a dental surgeon or
extractions or certain things that I may need at some points in
time, but I think there are areas where we could use some of
the systems or some of the approaches that are now available to
just better point out the need for oral care.
I know that like no other industry--in the nursing home, if
you focus on something, there is a very good likelihood of it
happening, especially when you connect it with MDS and other
survey issues. But I think that a lot of what I am seeing is if
we could just get the word out that oral care is something that
is urgent and important, just like we did several years ago
with restraint reduction--there was a huge decrease in
restraints once we put it back on the providers of services to
say this is a huge problem, we need to work together to solve
that problem--and we did, and I do not think there was a huge
cost to that.
So although there are a lot of costs and issues that we
have talked about that I don't think lend themselves to that, I
do think at least some focus on how we would approach oral care
in nursing homes is important.
The other point I would like to make--and it is no
different from what we struggle with in other parts of medicine
with our population, and I will use high cholesterol as an
example. We do not treat everybody who has high cholesterol in
the nursing home population because it is risk-benefit and it
is quality of life issues. So at some points, I think we also
have to look at what should we be treating and what do we not
necessarily have to treat. The Senator mentioned earlier about
whitening teeth. I am not really worried about cosmetic issues
in a lot of my patients. I am not sure--and I would defer to my
dental colleagues--whether I have to worry so much about
dentures, because I was taught that a lot of my patients could
actually gum their food. So I am not sure that dentures are as
important as pain, abscess, xerostomia, which I have seen huge
problems with. So how do we focus--the pain, the abscess, those
kinds of things in my severely demented patients are a quality
of life issue, so I would want to focus on the quality of life
issue, but I think we have to break down the population,
because the nursing home has dementia and end-stage and almost
palliative types of care, but there are all other subsets of
elderly in our population.
Ms. Heinrich. Yes?
Dr. Barsley. If I could add one thing that I do not think
has been addressed, or only on the margins, it would be to
increase interaction and educational interplay between
physicians and dentists.
I used to teach at the medical school and give lectures on
dental health to medical students. They were amazed at what we
brought them. Then we would bring them out to our clinic and
have them actually look into each other's mouths, and they were
further amazed by what was in the mouth besides the teeth.
So I think if we start at an early time and broaden that,
we would be benefited.
Ms. Heinrich. Karen.
Ms. Sealander. I think that the mere holding of this forum
is an important signal that this committee, and hopefully the
whole Senate, thinks that oral health is important. Hopefully
in the future, whenever Senators think of seniors' general
health, they will think of oral health as well.
We know how to prevent the principal oral maladies, and
despite this proven prevention capacity, we still have this
silent epidemic of oral disease which disproportionately
affects our vulnerable citizens, particularly the elderly. ADH
wants to be part of a collaborative solution to the problem of
oral health disparities and inadequate access to care. ADHA
believes that with the increasing number of hygienists, the
occupational growth, and with our focus on prevention that
dental hygienists are well-situated to play an important role.
One specific suggestion that ADHA offers is to ask the
committee to direct CMS to write to State dental directors,
asking them to facilitate the provision of Medicaid oral health
services by hygienists, specifically to recognize hygienists as
Medicaid providers of oral health services. Ten States already
do recognize hygienists as Medical providers and ADHA would
like to see the other 40 States follow suit.
Ms. Heinrich. Anyone else?
Dr. Folse. A couple of comments in closing for me. In
nursing facilities, I think there is an obvious partner there.
Some of the efforts that we have made have been along survey
issues, and I just want to assure you that that is not my focus
in my advocacy efforts and the work that I do with ADA and
special care dentistry. It is not about coming in with the
hammer; it is about we had that opportunity, so you go there.
But at the same time, we are doing all kinds of things to help
bring that industry up with oral health, working with the
American Medical Director Association. I and special care
dentistry for sure are seriously committed to working with your
industry trying to help in any way that we can. We have
education programs all day long that we can help you with.
Your point about not treating everyone is really well-
taken. I have patients with really bad oral conditions who,
because of the risk-benefit issues, I say we are not going to
be able to take care of these patients. So I am with you
there--education--we can all come to consensus with that.
Again going back to a foundation medically is the medical
necessity of oral services. I still think it is a medical
necessity.
Does anyone have disagreement with that? [No response.]
So one of the things that we could say from this forum--or
can we--is that we were all in agreement that oral health
services for vulnerable adults was medically necessary.
Are there any nays? I do not see any. OK. My dad was an
auctioneer.
Dr. Harrell. Actually, I would modify that and leave out
the ``vulnerable adults.'' Oral health care is essentially the
general health for anybody.
Dr. Folse. Thank you. I limit myself unnecessarily
sometimes.
I think in these State budgetary woes that everybody has,
if they would find their State problem and find some things
that they did not want to pay for, all they have to do is put a
set of lips on it. Once you get behind some lips, it does not
get any money, so it seems like it would help somewhere along
the way.
Personally, I have been involved with this forum, and we
have to thank Lauren Fuller who behind the scenes has done an
awful lot of work for the last 3 or 4 months, has taken endless
calls from Dr. Greg Folse--she probably does not want to hear
from me for 6 months, and even then, I am not sure--but we
really thank you for your work and your dedication to oral
health for elders across the country. You have started
something here, and it is going to be a fun ball to watch.
Before I let you close this, I want to thank each and every
one of you again for being here and participating, and those of
you in the audience who really care about oral health services
for our elderly, I thank you for being here also.
Ms. Heinrich. Well, I think you did a very nice job of
closing. I think it is easy to say that you have put
information together in one place, and yes, it is going to be
interesting to see how this moves forward.
Thank you all.
[Whereupon, at 4:05 p.m., the forum was concluded.]
A P P E N D I X
----------
[GRAPHIC] [TIFF OMITTED] T1118.024
[GRAPHIC] [TIFF OMITTED] T1118.025
[GRAPHIC] [TIFF OMITTED] T1118.026
[GRAPHIC] [TIFF OMITTED] T1118.027
[GRAPHIC] [TIFF OMITTED] T1118.028
[GRAPHIC] [TIFF OMITTED] T1118.029
[GRAPHIC] [TIFF OMITTED] T1118.030
[GRAPHIC] [TIFF OMITTED] T1118.031
[GRAPHIC] [TIFF OMITTED] T1118.032
[GRAPHIC] [TIFF OMITTED] T1118.033
[GRAPHIC] [TIFF OMITTED] T1118.034
[GRAPHIC] [TIFF OMITTED] T1118.035
[GRAPHIC] [TIFF OMITTED] T1118.036
[GRAPHIC] [TIFF OMITTED] T1118.037
[GRAPHIC] [TIFF OMITTED] T1118.038
[GRAPHIC] [TIFF OMITTED] T1118.039
[GRAPHIC] [TIFF OMITTED] T1118.040
[GRAPHIC] [TIFF OMITTED] T1118.041
[GRAPHIC] [TIFF OMITTED] T1118.042
[GRAPHIC] [TIFF OMITTED] T1118.043
[GRAPHIC] [TIFF OMITTED] T1118.044
[GRAPHIC] [TIFF OMITTED] T1118.045
[GRAPHIC] [TIFF OMITTED] T1118.046
[GRAPHIC] [TIFF OMITTED] T1118.047
[GRAPHIC] [TIFF OMITTED] T1118.048
[GRAPHIC] [TIFF OMITTED] T1118.049
[GRAPHIC] [TIFF OMITTED] T1118.050
[GRAPHIC] [TIFF OMITTED] T1118.051
[GRAPHIC] [TIFF OMITTED] T1118.052
[GRAPHIC] [TIFF OMITTED] T1118.053
[GRAPHIC] [TIFF OMITTED] T1118.054
[GRAPHIC] [TIFF OMITTED] T1118.055
[GRAPHIC] [TIFF OMITTED] T1118.056
[GRAPHIC] [TIFF OMITTED] T1118.057
[GRAPHIC] [TIFF OMITTED] T1118.058
[GRAPHIC] [TIFF OMITTED] T1118.059
[GRAPHIC] [TIFF OMITTED] T1118.060
[GRAPHIC] [TIFF OMITTED] T1118.061
[GRAPHIC] [TIFF OMITTED] T1118.062
[GRAPHIC] [TIFF OMITTED] T1118.063
[GRAPHIC] [TIFF OMITTED] T1118.064
[GRAPHIC] [TIFF OMITTED] T1118.065
[GRAPHIC] [TIFF OMITTED] T1118.066
[GRAPHIC] [TIFF OMITTED] T1118.067
[GRAPHIC] [TIFF OMITTED] T1118.068
[GRAPHIC] [TIFF OMITTED] T1118.069
[GRAPHIC] [TIFF OMITTED] T1118.070
[GRAPHIC] [TIFF OMITTED] T1118.071
[GRAPHIC] [TIFF OMITTED] T1118.072
[GRAPHIC] [TIFF OMITTED] T1118.073
[GRAPHIC] [TIFF OMITTED] T1118.074
[GRAPHIC] [TIFF OMITTED] T1118.075
[GRAPHIC] [TIFF OMITTED] T1118.076
[GRAPHIC] [TIFF OMITTED] T1118.077
[GRAPHIC] [TIFF OMITTED] T1118.078
[GRAPHIC] [TIFF OMITTED] T1118.079
[GRAPHIC] [TIFF OMITTED] T1118.080
[GRAPHIC] [TIFF OMITTED] T1118.081
[GRAPHIC] [TIFF OMITTED] T1118.082
[GRAPHIC] [TIFF OMITTED] T1118.083
[GRAPHIC] [TIFF OMITTED] T1118.084
[GRAPHIC] [TIFF OMITTED] T1118.085
[GRAPHIC] [TIFF OMITTED] T1118.086
[GRAPHIC] [TIFF OMITTED] T1118.087
[GRAPHIC] [TIFF OMITTED] T1118.088
[GRAPHIC] [TIFF OMITTED] T1118.089
[GRAPHIC] [TIFF OMITTED] T1118.090
[GRAPHIC] [TIFF OMITTED] T1118.091
[GRAPHIC] [TIFF OMITTED] T1118.092
[GRAPHIC] [TIFF OMITTED] T1118.093
[GRAPHIC] [TIFF OMITTED] T1118.094
[GRAPHIC] [TIFF OMITTED] T1118.095
[GRAPHIC] [TIFF OMITTED] T1118.096
[GRAPHIC] [TIFF OMITTED] T1118.097
[GRAPHIC] [TIFF OMITTED] T1118.098
[GRAPHIC] [TIFF OMITTED] T1118.099
[GRAPHIC] [TIFF OMITTED] T1118.100
[GRAPHIC] [TIFF OMITTED] T1118.101
[GRAPHIC] [TIFF OMITTED] T1118.102
[GRAPHIC] [TIFF OMITTED] T1118.103
[GRAPHIC] [TIFF OMITTED] T1118.104
[GRAPHIC] [TIFF OMITTED] T1118.105
[GRAPHIC] [TIFF OMITTED] T1118.106
[GRAPHIC] [TIFF OMITTED] T1118.107
[GRAPHIC] [TIFF OMITTED] T1118.108
[GRAPHIC] [TIFF OMITTED] T1118.109
[GRAPHIC] [TIFF OMITTED] T1118.110
[GRAPHIC] [TIFF OMITTED] T1118.111
[GRAPHIC] [TIFF OMITTED] T1118.112
[GRAPHIC] [TIFF OMITTED] T1118.113
[GRAPHIC] [TIFF OMITTED] T1118.114
[GRAPHIC] [TIFF OMITTED] T1118.115
[GRAPHIC] [TIFF OMITTED] T1118.116