[Senate Hearing 113-811]
[From the U.S. Government Publishing Office]
S. Hrg. 113-811
DENTAL CRISIS IN AMERICA:
THE NEED TO ADDRESS COST
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HEARING
BEFORE THE
SUBCOMMITTEE ON PRIMARY HEALTH AND AGING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING THE DENTAL CRISIS IN AMERICA, FOCUSING ON THE NEED TO ADDRESS
COST
__________
SEPTEMBER 12, 2013
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
TOM HARKIN, Iowa, Chairman
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington MICHAEL B. ENZI, Wyoming
BERNARD SANDERS (I), Vermont RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina RAND PAUL, Kentucky
AL FRANKEN, Minnesota ORRIN G. HATCH, Utah
MICHAEL F. BENNET, Colorado PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin MARK KIRK, Illinois
CHRISTOPHER S. MURPHY, Connecticut TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts
Pamela Smith, Staff Director
Lauren McFerran, Deputy Staff Director and Chief Counsel
David P. Cleary, Republican Staff Director
__________
Subcommittee on Primary Health and Aging
BERNARD SANDERS, (I) Vermont, Chairman
BARBARA A. MIKULSKI, Maryland RICHARD BURR, North Carolina
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin MICHAEL B. ENZI, Wyoming
CHRISTOPHER S. MURPHY, Connecticut MARK KIRK, Illinois
ELIZABETH WARREN, Massachusetts LAMAR ALEXANDER, Tennessee (ex
TOM HARKIN, Iowa (ex officio) officio)
Sophie Kasimow, Staff Director
Riley Swinehart, Republican Staff Director
(ii)
CONTENTS
__________
STATEMENTS
THURSDAY, SEPTEMBER 12, 2013
Page
Committee Members
Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health
and Aging, Committee on Health, Education, Labor, and Pensions,
opening statement.............................................. 1
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin.. 4
Franken, Hon. Al, a U.S. Senator from the State of Minnesota..... 39
Witnesses
Catalanotto, Frank A., DMD, Professor and Chair, Department of
Community Dentistry and Behavioral Science, University of
Florida College of Dentistry, and Vice Chair of the Board of
Directors, Oral Health America, Gainesville, FL................ 6
Prepared statement........................................... 8
Nycz, Greg, Executive Director, Family Health Center of
Marshfield, Inc., Marshfield, WI............................... 15
Prepared statement........................................... 16
Stallings, Cathi, MSW, Social Worker, Falls Church, VA........... 31
Prepared statement........................................... 32
Hughes, Debony R., D.D.S., Program Chief, Dental Health Program
and Deamonte Driver Dental Project, Prince George's County
Health Department, Cheverly, MD................................ 33
Prepared statement........................................... 35
(iii)
DENTAL CRISIS IN AMERICA: THE NEED TO ADDRESS COSTS
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THURSDAY, SEPTEMBER 12, 2013
U.S. Senate,
Subcommittee on Primary Health and Aging,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 a.m., in
room SD-430, Dirksen Senate Office Building, Hon. Bernard
Sanders, chairman of the subcommittee, presiding.
Present: Senators Sanders, Franken, and Baldwin.
Opening Statement of Senator Sanders
Senator Sanders. The hearing of the U.S. Senate
Subcommittee on Primary Health and Aging is going to begin. I
want to take this opportunity to thank all of the panelists who
are with us today, and I want to thank CSPAN for putting this
issue across the country. I also want to thank my colleagues,
who I expect will be coming in and out for this hearing.
In the last couple of years, we have had a lot of
discussion in our country about a dysfunctional healthcare
system in which some 50 million people have no health
insurance. We have a crisis in primary care, and despite poor
outcomes, we spend almost twice as much per person on
healthcare as do the people of many other countries.
Unfortunately, in the midst of the discussion about
healthcare in general, we have forgotten and paid very little
attention to an element of healthcare that is enormously
important to all Americans, and that is dental care and the
fact that we have a major crisis in dental care. And I'm glad
that CSPAN is here. I'm glad that everybody is here, because
this is an issue that needs a whole lot of discussion. It has
been kind of pushed under the rug, and it's time that we
brought it out into the sunlight.
Last year, I held a hearing on dental care, where we
learned that in the United States, we have a major crisis in
terms of oral health. Simply put, we learned that people who
need dental care the most are the least likely to get it, and
that is low- and middle-income Americans, racial or ethnic
minorities, pregnant women, seniors, individuals with special
needs, and those who live in rural communities.
For example, low-income kids are twice as likely as their
higher income peers to develop cavities, and lower income
adults are more than twice as likely as middle and higher
income adults to have had all of their teeth removed. And what
we know is, all over this country, there are kids who are home
today, not going to school because they have serious
toothaches. We know that this is a major problem that we are
neglecting.
What we also found is that in America today, millions and
millions of people live in towns and cities where it is
difficult to access dental care. Even if they might have some
insurance, they can't find a dentist who will treat them.
We learned that about 17 million low-income children
received no dental care in 2009. We learned that--and this is a
mind-blowing statistic--one-fourth of adults in the United
States ages 65 or older have lost all of their teeth. What
about that?
We learned that low-income adults are almost twice as
likely as higher income adults to have gone without a dental
checkup in the previous year. We learned that bad dental health
impacts overall health and increases the risk for diabetes,
heart disease, and poor birth outcomes. We learned that there
were over 830,000 visits to emergency rooms across the country
for preventable dental conditions in 2009, a 16 percent
increase over 2006.
In other words, when people are in agony, their only
alternative is to go into an emergency room, which, by the way,
is very expensive. The people in the emergency room are not
trained to deal with the dental problems. They deal with pain
relief. And that's how we are spending money on dental care.
We learned that almost 60 percent of kids age 5 to 17 have
cavities, making tooth decay five times more common than asthma
among children of this age. We learned that nearly 9,500 new
dental providers are needed to meet the country's current oral
health needs. However, there are more dentists retiring each
year than there are dental school graduates to replace them.
The dental crisis not only has high economic and financial
costs to individuals in our country, but it comes with high
social costs as well. Over $100 billion is spent every year on
dental services in the United States. Over a third of these
expenditures are paid out-of-pocket. Dental out-of-pocket
spending is second to spending on prescription drugs.
In addition to the billions that are spent, billions are
lost in missed school days and lost economic opportunity and
productivity due to dental pain. Tragically, sometimes people
become extremely ill because of oral infections, and, on
occasion, people die because they don't get the dental care
they need.
So let me be very clear. We are paying for this dental
crisis now in an inefficient, ineffective, and unjust dental
system where we spend money on those who come to our hospital
emergency rooms suffering in pain. And yet we refuse to provide
for people to get the care they need before it's too late. I
believe that making sure that people can get to the dentist
when they need to will prevent not only a lot of suffering, but
at the end of the day, saves our country money as well.
Interestingly enough, last year, I asked the people of
Vermont and people all over the country to send me their
stories about dental access problems. We were just blown away
by the kind of response that we got. We had 1,200 responses. I
think people are never asked to talk about it. What we heard
was people who are in pain, who can't find a dentist, who worry
about their kids. It was really quite something.
I think we have a real problem that needs to be discussed.
When we talk, by the way, about the concept of insurance, we
usually mean that insurance covers the need. But I think most
people understand that dental insurance often pays for a
relatively small percentage of one's needs. The average benefit
cap is just about $1,500 a year, and, as everybody knows,
dental care is extremely expensive.
I hope today our panel will help us to understand why
dental care is so very expensive. If you have some serious
dental problems, $1,500 is not going to do it. Despite these
limits, people with dental insurance are far more likely to see
a dentist than those who have no coverage at all. More than one
out of every four Americans does not have any dental insurance.
Traditional Medicare--and I see this every day. I don't
know, Senator Baldwin, if you run into this as well. But
seniors often come up to us and say, ``Why is Medicare not
covering dental services?'' And it certainly does not.
I am chairman of the Senate Committee on Veterans Affairs,
and I can tell you that right now--and this is an issue we're
working on--the VA does not cover dental care, except for
service-connected problems, for our veterans. And States can
choose whether their Medicaid programs provide coverage for
dental care for lower income adults. Some do a good job. Many
do not, which means that low-income Americans with Medicaid in
nearly half of the States have no dental benefits or can
receive services only in the case of a dental emergency.
To my mind, it is unacceptable, but in our country,
millions of people cannot get the care they need to live
healthy lives. Dental problems, although entirely preventable,
can lead to extreme pain.
Another issue is the stigma of missing teeth. If I'm
looking for a job, and I don't have my front teeth, what do you
think my potential employer is going to say? He would say,
``Actually, you're not the guy we want right here.'' So when
you have no teeth in your mouth, it's like a P on your
forehead, saying, ``This is a poor person. This is a person we
don't want in our workplace.'' That's an issue that we have to
address as well.
The lack of access to dental care and the high cost of
dental care are national problems. But as is often the case,
the problems are far more acute for lower income Americans. For
many people with Medicaid, for example, it is almost impossible
to find a dentist who will see them.
Medicaid is inadequate, but even if you do have Medicaid,
it is, in many cases, impossible to find a dentist who will
serve you. Only 20 percent of dentists accept Medicaid, and
only a small percentage of dentists dedicate a significant
portion of their practice for the underserved.
When I ask about the high cost of dental care, I am often
reminded that most dentists work in small private practices
where the overhead is high, and dental school is extremely
expensive. That is another very important issue that I hope we
can touch upon, the outrageously expensive cost of dental
school, people graduating with hundreds of thousands of dollars
in debt.
But in a report released today, just today, the Government
Accountability Office, the GAO, found wide variations in fees
charged by dentists. For eight of 24 common procedures the GAO
examined, those charging at the high end charge more than
double what those with average fees charge their patients.
That's a whole other issue, why the cost of dental care is so
expensive and the discrepancy in prices that we see all over
the country.
There is some good news out there, and we're going to hear
some good news today. The good news is that we are making
progress in expanding the number of locations where lower
income people and working people can get access to dental care.
FQHCs, Federally Qualified Health Centers, provide dental
services to more than 4 million Americans across the country,
regardless of their ability to pay.
Under the Affordable Care Act, I and others worked very,
very hard to expand FQHCs to the tune of some $12 billion or
$13 billion and to put money into the National Health Service
Corps so that we can help dentists get their student debts paid
by the government so they can work in underserved areas.
More than 90 percent of those that receive care at FQHCs
have incomes that are 200 percent or below the Federal poverty
line. I know in Vermont, we are having some success. We have
about 25,000 people getting their dental care now through
FQHCs.
We have established school clinics, and they are working
really well in at least two locations where there's a beautiful
dental clinic right in the school. Kids are coming in. In some
cases, adults are coming in. That's a concept that I like very
much, and maybe we can talk about that.
Later this month, I intend to reintroduce the Comprehensive
Dental Reform Act. This bill addresses the dental crisis in
America by expanding coverage to people with Medicare,
Medicaid, veterans health benefits, and the Affordable Care Act
to significantly increase the number of people with insurance,
expanding the number of places where people can seek care,
enhancing the workforce, and improving education to respond to
the needs of the underserved.
While this bill will, in fact, cost money--it is an
expensive bill--it is worth repeating that we're already paying
huge sums for dental care through emergency room visits,
hospital stays, and lost wages and productivity. The bottom
line is we have a crisis in this country in terms of dental
care. We are wasting huge amounts of money, and it is time to
make sure that every American gets the dental care he or she
needs and to make sure that we especially take care of our
kids.
Senator Baldwin, I understand that you're going to have to
be leaving us soon and you wanted to make an introduction of
one of our panelists.
Statement of Senator Baldwin
Senator Baldwin. If I could make an opening statement and
then----
Senator Sanders. Sure.
Senator Baldwin. I can stay for a little while.
Senator Sanders. Great. Great to have you.
Senator Baldwin. So we can do it in the regular order you
planned, Mr. Chairman.
I want to thank you, Mr. Chairman, for holding this very,
very important hearing.
I appreciate the chairman's longstanding commitment to
extending quality affordable dental care to all Americans. Far
too many Americans do not have access to dental care. One of my
constituents recently wrote to me and said that American dental
care is unfortunately stratified into two buckets, the haves
and the have nots. For those who currently lack access, the
have nots, we must promote policy to expand coverage, including
investing in Federally Qualified Health Centers.
I'm pleased to have Mr. Greg Nycz here from the Family
Health Center of Marshfield, WI. Mr. Nycz's center has been
instrumental in expanding dental care to vulnerable populations
in rural areas and tribal areas in the State of Wisconsin. He
will shortly be offering some keen insight on the benefits of
the health center model.
For the haves, those Americans who currently have access to
dental care, that care has grown significantly more expensive
over recent years, putting a lot of stress on middle-class
families' budgets. We have to do all that we can to address
these increasing costs, because they ultimately threaten public
health and economic security.
But major opportunities exist at this moment. As we move
forward with reforms to our underlying healthcare system,
reforms that focus on delivering healthcare of higher quality
at a lower cost, dental care must be an integral part of those
changes and those reforms.
First, ensuring access to dental care must be a major
component of investing in preventative services so that we can
save costs later by helping people avoid developing chronic
diseases. Second, dental care should become more integrated
into healthcare models. We need to tear down those artificial
barriers that exist between dental and medical. They are
artificial barriers. By delivering more integrated care, we
will decrease cost and improve the quality of care.
I look forward, Mr. Chairman, to the testimony of today's
panel. I can remain a little longer and would love the
opportunity to introduce my constituent when that moment
arrives.
Senator Sanders. Thank you very much, Senator Baldwin, for
your hard work on this issue.
Let me now take the opportunity to introduce our panelists.
Our first witness is Dr. Frank Catalanotto.
Dr. Catalanotto is a dentist and a professor and chair of
the Department of Community Dentistry and Behavioral Science at
the University of Florida College of Dentistry in Gainesville.
He is also vice chair of the board of directors of Oral Health
America.
Senator Baldwin, do you want to introduce Mr. Nycz?
Senator Baldwin. Thank you, Mr. Chairman. It is my great
pleasure to introduce Mr. Greg Nycz. Mr. Nycz is the director
of the Family Health Center of Marshfield, WI, which is a
Federally Qualified Health Center. Mr. Nycz has been involved
with the planning and operation of the Family Health Center for
over 40 years.
The Family Health Center of Marshfield is one of the
largest FQHC dental practices in the Nation and the largest
provider of dental services to Medicaid patients in the State
of Wisconsin. I have always admired the work that the Family
Health Center has done to increase access to care in my home
State.
Mr. Nycz, I will look forward to your testimony today.
As you noted, Mr. Chairman, unfortunately, I'm going to
have to leave midway through the testimony.
But thank you so much for being here.
Senator Sanders. Thank you.
Our next panelist will be Cathi Stallings. Ms. Stallings is
a social worker from Falls Church, VA, who has seen firsthand
both personally, as I understand it, and professionally, the
need to increase access to affordable dental care. She received
her master's in social work from Virginia Commonwealth
University.
We thank you for being with us.
Our final witness is Dr. Debony Hughes. Dr. Hughes has
worked at the Prince George's County Health Department for 17
years and has served as the Program Chief of Dental Health
there since 2007. In this role, she oversees the Deamonte
Driver Dental Project. She also serves on the Maryland Dental
Action Coalition Board. She began her public health career as a
dentist in Bristol, VT. But she left us.
[Laughter.]
Again, I want to thank all of you for being here. What we
are trying to do and what this hearing is about is to focus
attention on a crisis which does not get the discussion that it
needs. It's going to be a long, hard fight, but that's what
we're trying to do.
Dr. Catalanotto, thank you for being here. Please make your
presentation.
STATEMENT OF FRANK A. CATALANOTTO, DMD, PROFESSOR AND CHAIR,
DEPARTMENT OF COMMUNITY DENTISTRY AND BEHAVIORAL SCIENCE,
UNIVERSITY OF FLORIDA COLLEGE OF DENTISTRY, AND VICE CHAIR OF
THE BOARD OF DIRECTORS, ORAL HEALTH AMERICA, GAINESVILLE, FL
Mr. Catalanotto. Mr. Chairman, members of the subcommittee,
thank you very much for the opportunity to talk about access to
oral healthcare. My name is Frank Catalanotto, and I've spent
almost 40 years in dental education but for the last 20 years
have been advocating for a better way to deliver oral
healthcare.
There are several indicators about this access problem that
I'd like to mention. First, dental care utilization has
declined about 10 percent in the last decade among low-income
people, primarily for cost.
Second, we have made some good progress in the last decade
to improve access to care for children. But we still have
approximately 60 percent of Medicaid enrolled children who are
not receiving proven, cost-effective, and preventive dental
services. And, third, as the Senator said, hospital emergency
room visits for dental problems have increased 16 percent to
over 830,000 visits in 2009, a very significant wasted cost.
What are the effects of this lack of access to care? Two
examples: First, children who miss school because of dental
problems do less well in school than other children. Education
is the way out of poverty, but children in pain cannot learn.
Second, a recent study from 2000 to 2008 showed that 61,000
patients across the country were hospitalized for a preventable
dental infection. And Deamonte Driver was not an isolated
example. Sixty-six deaths were reported in this study at an
estimated cost of $840 million. This is not a personal tragedy
only. This is an economic loss.
Let me mention dental schools. Dental schools are an
important part of the dental safety net, with faculty and
students that actually do provide care outside of the dental
school in community-based settings accessible to the
underserved. But dental education is very lengthy and
expensive. That makes dentists a very expensive part of the
healthcare team.
The 165,000-plus dentists in the United States provide high
quality dental care to those patients who can afford their
services. Unfortunately, many of these dentists do not
participate in the Medicaid program. There are many reasons for
this, including low reimbursement rates. But no matter the
reason, this significantly reduces access for many patients.
Dentists provide significant pro bono care. However, I
would remind you that while philanthropic care is wonderful,
philanthropy is not a healthcare system and does little for
long-term oral health care.
Another concern I have and others have is that there are
restrictive State dental practice acts that do very little to
actually protect the health of the public and can specifically
impede improving access to oral healthcare. I'll give two
specific examples in a minute.
What are some of the potential solutions to this access
problem? I will only focus on workforce, although there are
many others. A new dental workforce model, at least new to the
United States, is the dental therapist.
These therapists are members of the oral healthcare team
who provide preventive and limited restorative care to their
patients. They have been employed in over 50 countries for over
90 years. They come from the ethnically and economically
diverse communities they go back to serve.
They are inexpensive to educate. They are cost-effective to
hire. They are safe practitioners, no matter what else you may
hear. They are currently employed in Alaska and Minnesota.
There are at least 15 other States working to include them, but
they are being blocked by restrictive dental practice acts at
the State level and by the American Dental Association at the
national level.
Second, a more cost-effective location for delivering
dental care is in a large group practice setting that employs
multiple dentists and thus has lower overhead than the
traditional dentist-owned single dental practices, thus
reducing cost. One example you'll hear about in a minute. But
another example is the not-for-profit Sarrell Dental Centers of
Alabama that provide excellent comprehensive care. In the past
8 years, they have grown from 15 sites to nearly 500,000, using
a combination of a culture of caring, evidence-based practice,
innovative business practices, marketing, and community
outreach.
Let me leave you with this last sentence, what Sarrell has
done. They have reduced cost to the Medicaid program from an
average annual cost in 2005 of $328 to $125 in 2012. This is a
remarkable business model that takes care of patients.
We need more of these around the country. We can't, because
there are some States that have a restrictive dental practice
act that will not allow a business like Sarrell to be owned by
a non-dentist. This is ludicrous when the major hospitals in
this country are run by MBAs.
In closing, I'd like to point out that Congress is lobbied
by many members of the dental industry, including dental
academics. But who lobbies for the patient for increased access
to care, for oral health services that prevent pain and
suffering, for increased ability to learn and work, and for
lower cost? I would suggest that we need you in your leadership
roles in Congress to fight for those patients.
Thank you very much, Senator.
[The prepared statement of Mr. Catalanotto follows:]
Prepared Statement of Frank A. Catalanotto, DMD
Mr. Chairman, members of the subcommittee, thank you very much for
the opportunity to speak with you this morning about access to oral
health care in the United States. My name is Dr. Frank Catalanotto. I
am a children's dentist who has spent almost 40 years in dental
education and for the last 20 years, advocating for a better way to
deliver oral health care. I am currently the Chair of the Department of
Community Dentistry at the University of Florida College of Dentistry.
I am here this morning to ask your assistance in improving access to
oral health care in the United States.
1. challenges facing the united states related to oral health care
There are several indicators I can share with you that clearly
illustrate the lack of access to oral health care in this country.
First, Dental Care Utilization has declined among low-income adults
over the past decade (ADA Health Policy Resource Center); over 35
percent of low-income seniors have not seen a dentist in over 4 years,
primarily because of costs. Second, while we have made significant
progress in improving access to care for children, there are about 48
percent of Medicaid enrolled children who are not receiving preventive
dental services and about 77 percent of these children are not
receiving restorative services. Third, according to a study released by
the PEW Children's Dental Campaign in 2012, the number of Americans who
have gone to hospital emergency rooms for dental pain and infections
has increased 16 percent from 2006 to 2009; this included over 830,000
such dental visits. Hospital dental emergency rooms are very
expensive--in Florida in 2010, there were over 115,000 such visits
costing over $88 million, and they are very inefficient since for most
visits, the physicians prescribe antibiotics and pain medication and
suggest the patient see a dentist the next day, something these
patients cannot afford.
What are the effects of this lack of access to oral health care?--A
number of recent scientific reports, some by United Concordia
Insurance, have shown that preventive dental care can reduce overall
medical care costs for patients with diabetes and heart disease.
Imagine if these benefits could be extended to the entire population
and how that might help reduce overall health care costs in the United
States. Second, several studies have now shown that children who missed
school because of dental problems did less well in school than children
who missed school for other reasons. Education is a way out of poverty,
thus, to me; there is a clear economic advantage to having improved
access to dental care. Third, a recently published study showed that
over a 9-year period from 2000-8, a total of 61,439 patients were
hospitalized because of a dental infection. More important, a total of
66 patients died during these hospitalizations, all for lack of access
to quality preventive dental care. This is a personal tragedy, not just
an economic loss.
2. the role of dental education in addressing lack of access
Dental schools educate a highly competent workforce and conduct
research to address the oral health needs of our county. Congress has
recognized the importance of dental schools and funds HRSA to provide
grants to support modernizing and reshaping dental education to meet
the changing needs of the oral health workforce with a particular focus
on health care disparities. Our team actually has several of these
grants at the University of Florida and for that I am grateful. For
example, dental schools across the country are working hard to recruit
a dentist workforce that better mirrors the racial and economic
diversity of our country. Dental schools are an important part of the
dental safety net, providing much care in community-based settings such
as federally Qualified Health Centers. But I would also add that dental
education is very expensive, making dentists a very expensive part of
the oral health care team.
3. the role of the practicing dentist and the american dental
association
The 100,000 plus dentists in the United States provide high quality
dental care to a large number of patients. Unfortunately, many of these
same dentists do not participate in the Medicaid program; for example,
in Florida, only about 12 percent of dentists see Medicaid patients.
There are many reasons for this including low reimbursement rates and
the very high overhead of dental practice making it somewhat cost-
inefficient, but, no matter the reason, this significantly reduces
access for many patients.
In addition, these dentists provide significant pro-bono care
either in their offices or through such events as Missions of Mercy in
which large numbers of dentist convene in a large facility or even
tents and patients line up sometimes a day in advance to obtain some
limited care. However, I would submit to you that while philanthropic
care is wonderful, philanthropy is not a health care system and does
little for long-term oral health. Another concern is restrictive dental
practice acts that do little to help protect the health of the public
and can really impede improving access to oral health care. I will give
two specific examples at the end of my remarks.
4. what are some potential solutions to this access problem?
I categorize these potential solutions into three groups including
in the accompanying Power Points including dental insurance, patient
education and workforce. Because of the limited time, I will only focus
my comments on workforce: Bottom Line--we need an oral health workforce
that is less expensive than dentists to deliver routine dental services
so that dentists can focus on more complex procedures and we need
workforce locations that are more efficient and cost-effective than
private dental practices with their high overhead.
First, a comment about ``The Comprehensive Dental Reform Act of
2013.'' This legislation extends dental insurance to millions of
Americans. A number of other components will really help improve the
oral health workforce in ways I will now address in my closing
comments. But thanks for this legislation.
A new dental workforce model--new to the United States--is the
dental therapist. These therapists are members of the oral health care
team who can provide preventive limited restorative dental care to
patients under the supervision of a dentist. They have been employed in
over 50 countries around the world for over 90 years. They are usually
recruited from the ethically and economically diverse communities they
return back to serve. They are inexpensive to educate and cost-
effective to hire. They are safe practitioners, no matter what else you
may hear. They are currently employed in the United States in Alaska
and Minnesota. There are at least 15 other States who are working to
include dental therapists in the workforce but these efforts are being
blocked by organized dentistry and the restrictive dental practice acts
I mentioned earlier.
Second, a more cost-effective location for delivering dental
practices is a large practice setting that employs several dentists and
other oral health care providers and thus has a lower overhead than the
traditional dentist-owned single dentist practices. The recent Senate
Report on Corporate Dentistry has illustrated some concerns about the
profit-driven, equity-backed corporate model but there are excellent
not-for-profit models such as the Sarrell Dental Centers of Alabama
that provide excellent comprehensive preventive oriented care to low-
income patients. In the past 8 years, Sarrell has grown to 15 sites
providing care to nearly 500,000 Medicaid recipients. Uses a
combination of a ``Culture of Caring'', evidence-based dental
practices, innovative business approaches, marketing and community
outreach. Most importantly, they have demonstrated a decline in the
average Medicaid reimbursement from $328 in 2005 to $125 in 2012. This
is a truly unique model of dental practice. Unfortunately, many State
dental practice acts across the country prevent dental practices from
being owned and managed by non-dentists, something done across the
country by medical groups and hospitals. We could use congressional
help in expanding the Sarrell and similar models across the country.
In closing, I would like to point out Congress is lobbied by many
members of the dental industry including dentists, dental schools,
dental industry, and insurance companies. But who lobbies for the
patient for increased access to preventive and therapeutic oral health
services that can prevent pain and suffering, increase ability to learn
and work, and eventually help lower health care costs. I would suggest
that we need you as elected Members of Congress to help these patients.
THANK YOU!
______
University of Florida College of Dentistry
``Dental Crisis in America: The Need to Address Cost''
frank a. catalanotto, dmd--who am i?
Educated as a pediatric dentist, 39-year career in dental
education, past president of the American Dental Education Association,
former dean at University of Florida, now chair of Department of
Community Dentistry and Behavioral Science (Public Health).
Committed to improving access to oral health for all by
education oral health services research, and advocacy.
Vice chair, board of directors, Oral Health America.
Chair, Leadership Council, Oral Health Florida.
Viewpoint expressed this morning is my own and does not
necessarily reflect the views of the University of Florida, Oral Health
America or Oral Health Florida.
what can i cover in 5 minutes?
Challenges to U.S. oral health care system.
Role of Dental Education:
educating workforce, and
safety net provider.
Role of the practicing dentist and the American Dental
Association--Philanthropic Care, Regulation and Restrictive Dental
Practice Acts.
Consolidation in the dental industry. Role of:
corporate/for profit models of dental practice; and
large scale not-for-profit models (e.g., Sarrell).
Potential solutions:
insurance,
new workforce models, and
large, cost-effective not-for-profit dental practices.
challenges: indicators of lack of access to oral health care
Adults not seeking dental care.
Children doing better but still a serious lack of access
and utilization.
Hospital Emergency Room for dental care is increasing; but
hospital ERs do not solve the problem. ``Pay me now or pay me later.''
who are these people with disparities of access and oral health?
The Culture of Poverty
``Many of us have no real understanding of what poverty is. We may
be broke most of the time, in debt, unsure of how we'll pay the phone
bill. But those particular definitions can apply to middle class.
Poverty is something else. Missed meals, a reliance on government aide,
homes without power or telephone services--these are the earmarks of
the culture of poverty.''
Those in POVERTY, patients on Medicaid, CHIP.
Racial and Ethnic minorities.
Traditionally, children, the elderly, rural, single
mothers.
The uninsured, including the working poor.
Any who do not understand the importance of optimal oral
health.
Increasingly in this recession, lower middle-class and
middle-class families. WORKING FAMILIES
Dental Care Utilization Declined Among Low-Income Adults and Increased Among PLow-Income Children in Most States
From 2000-2010
(ADA Health Policy Resource Center)
----------------------------------------------------------------------------------------------------------------
Children Adults
---------------------------------------------------------------------------------
2000 2010 % Change 2000 2010 % Change
----------------------------------------------------------------------------------------------------------------
U.S. overall.................. 27% 41% 53% 54% 48% -10%
----------------------------------------------------------------------------------------------------------------
*Note both still below 50 percent.
adult dental care
The decrease in adults seeking dental care cuts across
economic groups with reductions in upper income, middle income and 6
percent lower income groups. REASON--COSTS.
Recent HARRIS--Oral Health America Poll. Almost half of
older adults with incomes of $35,000 or less have not been to the
dentist in 2 years and 35 percent of all lower income older adults have
not sought dental care in the last 4 years. REASON--COSTS
Table 4: Children Age 1-20 Enrolled in EPSDT for at Least 90 Continuous Days Who Received a Preventive Dental
Service, or a Dental Treatment Service in Fiscal Year 2011
----------------------------------------------------------------------------------------------------------------
Percent
Total children Percent Total children Children
receiving a Children receiving a receiving a
REGION preventive receiving a dental dental
dental service preventive treatment treatment
dental service service service
----------------------------------------------------------------------------------------------------------------
U.S. Overall.................................... 13,550,097 42.2 7,466,214 23.3
----------------------------------------------------------------------------------------------------------------
Source: Fiscal Year 2011, CMS-416 Reports.
A Costly Dental Destination--Hospital Care Means States Pay Dearly
pew childrens dental campaign-issue brief 2012
Preventable dental conditions accounted for 830,590 visits
to ERs nationwide in 2009.
a 16 percent increase from 2006.
Emergency rooms are the first and last resort because
their families struggle to find a dentist who either practices in their
area or accepts Medicaid patients.
pay me now or pay me later
Hospital ER visits do not provide ``treatment'' of the
underlying dental problem, only relief of symptoms of pain and
infection.
Hospital ER visits cost money to Medicaid and insurance
but for the uninsured, the hospitals usually absorb those costs. In
other words, you/we are already paying for dental care for these
patients.
Makes more sense to pay up front for increased access and
preventive and restorative dentistry.
We need insurance and oral health professionals who are
willing to work in underserved communities to provide these services to
patients who cannot afford traditional dental services.
effects of lack of access to oral health care
Oral Health and overall body health.
Effects on School Learning in children.
Morbidity and Mortality.
oral health and overall body health
New recently published reports showing lower annual health
care (MEDICAL) costs for patients with chronic disease processes such
as diabetes and heart disease if these patients have been treated
successfully for periodontal disease and continued to maintain their
periodontal health. The savings noted were significant.
Visit the UCH Wellness Oral Health Study on United
Concordia Web site to learn more.
Impact of poor oral health on children's school attendance and
performance \1\
---------------------------------------------------------------------------
\1\ Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Am J Public
Health. 2011 Oct;101(10):1900-6. doi: 10.2105/AJPH.2010.200915. Epub
2011 Feb 17. PMID: 21330579 [PubMed--indexed for MEDLINE].
---------------------------------------------------------------------------
Children who missed school days because of dental problems
did less well in school than children who missed school for other
reasons.
outcomes of hospitalizations attributed to periapical abscess
from 2000 to 2008: a longitudinal trend analysis \2\
---------------------------------------------------------------------------
\2\ J Endod. 2013 Sep;39(9):1104-10. doi: 10.1016/
j.joen.2013.04.042. Epub 2013 Jul 11.
---------------------------------------------------------------------------
During the 9-year study period (2000-8), a total of 61,439
hospitalizations were primarily attributed to dental/tooth infections
in the United States. A total of 66 patients died in hospitals.
This is not only a ``cost issue,'' this is a life and death issue!
role of dental education
Academic Dental Institutions include dental schools and
allied dental education programs.
Educate and train a highly competent workforce and conduct
research to address oral health needs of the country.
Congress via HRSA has been very supportive of need for
grants to support modernizing and reshaping dental education to meet
changing needs of the oral health workforce with a particular focus on
health care disparities.
Academic Dental Institutions are a very important part of
the safety net for underserved patients.
Using our admissions policies to recruit a workforce that
represents the diversity of the United States.
University of Florida Statewide Network for Community Oral
Health sends students out to work in community settings such as
Federally Qualified Community Health Centers.
HOWEVER, educating dentists is a very expensive component
of the dental workforce.
role of the practicing dentist and the american dental association
The 100,000-plus dentists in the United States provide
high quality care to a large number of patients.
These dentists provide significant pro-bono care to the
underserved in their practices, in philanthropic clinics, and in
national events such as Give Kids a Smile days and Missions of Mercy
(MOM) events.
dentists and medicaid patients \3\
---------------------------------------------------------------------------
\3\ (*Published; **in preparation by my team.)
---------------------------------------------------------------------------
Low Reimbursement* (but increasing rates does not always
work).
Administrative hassles* (this is real).
Medicaid patients do not keep appointments* (but they
can!).
Do not want to mix Medicaid and other patients in waiting/
reception room.*
Sense of Social Justice.*
Social Stigma of being a Medicaid provider.**
philanthropy--missions of mercy
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
While philanthropic care is wonderful, I would submit to you that
philanthropic care is not a health care system and does little for
long-term oral health.
there is a body of literature on restrictive practices in dental
licensing \4\ \5\ \6\
---------------------------------------------------------------------------
\4\ Doyle, Roger, License to Work, Scientific American, 296:2,
February, 2007.
\5\ Kleiner, Morris and Kudrle, Robert, Does Regulation Affect
Economic Outcomes? The Case of Dentistry, Journal of Law and Economics,
43:2, 547-82, October 2000.
\6\ Freund, Deborah and Shulman, Jay, Regulation of the
Professions: Results from Dentistry, Advances in Health Care Economics
and Health Services Research, 5:161-80, 1984.
---------------------------------------------------------------------------
Purpose of regulation (State dental practice acts) is to
safeguard the health of the public and promote competition.
Substantial literature says this does not occur.
In fact, the more restrictive the dental practice act, the
higher the income of the practitioners and no demonstrable effect on
the health of the public.
Many State dental practice acts forbid a non dentist from
owning a dental practice as will be discussed with a not-for-profit
model in a few minutes.
Such restrictive regulation negatively impacts access for
the underserved.
potential solutions
Insurance for oral health services
Patients with insurance are healthier than patients
without insurance.
Educate patients and change their behavior
Evidence-based practices.
Culturally competent practitioners.
Workforce
More dentists--a very expensive solution.
Expanded work settings and reimbursement models for
dental hygienists.
New workforce settings and business models.
New models of oral health care professionals.
insurance for oral health services--``the comprehensive dental
reform act of 2013''
Extends comprehensive dental health insurance to millions
of Americans.
A number of other components of this bill will really help
improve oral health workforce and access to oral health care.
new workforce models--dental therapists
Dental Therapists are oral health care team members that
can provide preventive and limited restorative care to patients under
the direct supervision of dentists.
Over 90 years of evidence in over 50 countries that they
are safe and effective oral health care providers.
Come from the local community, cultural competency.
Excellent capacity for case management, patient education,
restorative and limited surgical care. Inexpensive to educate and hire.
Recent studies/reports in the United States clearly
demonstrate quality, safety and cost effectiveness.
Currently in use in Alaska and Minnesota. About 15 other
States are considering this model of care.
Being blocked by restrictive dental practice acts and
vigorous opposition by organized dentistry.
Training grants authorized by Congress but appropriations
blocked in recent years.
Native American Tribes in the ``lower 48'' would like to
utilize Dental Therapists but are being blocked by Congress as a result
of lobbying by dentists.
workforce--corporate models
Senate Report on Corporate Models of Dental Practice.
Corporate models are on the increase because of the
efficiency and cost effectiveness.
Have the potential to provide lower cost care and
better access to the underserved.
Senate report correctly drew attention to some
equity-backed corporate models that have a profit motivation to
over-treat patients.
But we should not overlook the role of large, not-
for-profit models that have an excellent track record of care.
sarrell dental centers of alabama
A not-for-profit corporate model that works.
In 8 years, have grown to 15 sites providing care to
nearly 500,000 Medicaid recipients.
Uses a combination of a ``Culture of Caring,'' evidence-
based dental practices, innovative business approaches, marketing and
community outreach.
Demonstrated a decline in the average Medicaid
reimbursement from $328 in 2005 to $125 in 2012.
So, why not expand this model across the United States?
Strong opposition from the Alabama Dental Association that
was only resolved by legislation and intervention by the FTC.
Many dental practice acts across the country prevent
dental practices from being owned and managed by non-dentists,
something done across the country by medical groups and hospitals.
closing and thank you
Congress is lobbied by many members of the dental industry
including dentists, dental schools, dental industry, insurance
companies.
But who lobbies for the patient for increased access to
preventive and therapeutic oral health services that can prevent pain
and suffering, increase ability to learn and work, and eventually help
lower health care costs.
I would suggest that we need you as elected Members of
Congress to help us as patients.
Senator Sanders. Thank you very much.
Mr. Nycz.
STATEMENT OF GREG NYCZ, EXECUTIVE DIRECTOR, FAMILY HEALTH
CENTER OF MARSHFIELD, INC., MARSHFIELD, WI
Mr. Nycz. Good morning, Senator Sanders.
And thanks for the kind introduction, Senator Baldwin.
I want to thank the subcommittee for the opportunity to
testify today on a topic I am passionate about, the need to
improve access to dental care in our country.
I'm here representing Family Health Center of Marshfield,
the center that serves a large region in Wisconsin
approximately the size of the State of Maryland. About a third
of our residents are poor or near poor.
Twenty years ago, I served on the Wisconsin Dental
Association's Access to Care Committee as their only non-
dentist. In that role, my phone number was listed as a resource
for people seeking dental care. I took many calls.
One day, I picked up the phone, and it was a young mother,
failing to hold back the tears as her child screamed in pain
and sobbed uncontrollably. The mother broke down. She had been
trying for days, calling over 30 dental offices for help,
someone who would stop her child's pain.
Such conversations were not uncommon for me back then. But
what made this conversation a life changer for me was that I
came to realize as I spoke with her that she was not just
bearing the burden of her child's pain, but also the self-
imposed pain that came with her conclusion that she was a
failure as a mother.
I'm proud of Wisconsin, and I'm proud of my country. But
none of what that mother was enduring had to be, because it was
all preventable, and there's really no mystery associated with
how to fix it.
After a decade of frustration, trying to improve the system
and using traditional routes, my board said, ``Find another
way. This is your top priority.'' Ten years later--and I
brought a picture to show this--we've served nearly 100,000
folks. Even we were surprised by the enormous response.
Our patient origin map shows that in spite of the fact that
we are located in northern Wisconsin, we've seen State
residents from every county and 73 percent of our State's zip
codes. Our patients tell us where we are needed.
When we established our Park Falls clinic, over 1,000
people traveled over 412,000 miles to get care with us at Park
Falls, mostly from the Rhinelander area. Today, we have a
clinic in Rhinelander as a result of that.
The folks who lacked access, the elderly, those on
Medicaid, and the uninsured poor, we knew about. But what
surprised us was that veterans with limited incomes could not
get care. Today, they now have a place to go.
Those who journey the farthest are disproportionately
people of all ages who have emergency dental needs and
caregivers who bring their developmentally disabled loved ones
for care at our sites--another group that is left behind.
Recall the quote from Alice in Wonderland, ``If you don't
know where you're going, any road will get you there.'' We knew
to get to our preferred future, we would need societal
investment. So we have been relentless in looking for ways to
maximize the value of our efforts for the taxpayer, not just
the patients we serve.
We learned that we could improve the performance of our job
placement agencies by making job seekers with horrible oral
decay more presentable and employable. One of our counties with
about 34,000 in population told us that they have about 100
such adults every year.
We learned that annual savings on the medical care side
possibly in the range of $2,000 to $3,000 are possible for
patients with diabetes if we give them proper dental care. And
we learned we could be a real alternative to the emergency room
and the hospital by opening our doors to patients with dental
emergencies from across the State.
I would like to leave you with three thoughts. First,
success will require that we fundamentally work to change our
Nation's perspective on the importance of oral health in its
own right and the added value oral health brings to general
health.
Second, workforce matters. Over the next 20 years,
Wisconsin may face 2.2 dentists retiring for each new dentist
entering practice. And new graduates need to be better prepared
to face more elderly patients with complex multiple medical
conditions.
Third and perhaps most importantly, at the community level,
we are seeking to accomplish this by pursuing an integrative
medical-dental model that leaves no one behind. This is the
missions of all health centers. We are solving healthcare
access problems one community at a time, and we're in 9,000
communities.
But the current demand for care is outpacing our growth.
Over 300 of us applied for funding to meet unidentified unmet
dental needs in 2011. Unfortunately, a last minute budget deal
cut $600 million from planned health center funding, and there
have been no opportunities to fund oral health expansion since
then.
Our Nation's health centers are your health centers. The
health center model has what it takes to solve the oral health
disparity problems for a growing number of our Nation's
communities. And I appreciate Congress' past support of health
centers and ask that you continue to invest in our Nation's
health centers. Give us more work, for there is more work to be
done.
Thank you.
[The prepared statement of Mr. Nycz follows:]
Prepared Statement of Greg Nycz
Good morning Chairman Sanders, Ranking Member Burr, and
distinguished members of the Subcommittee on Primary Health and Aging.
My name is Greg Nycz and I want to thank you for the opportunity to
testify today before the subcommittee. I am the executive director of
Family Health Center of Marshfield, Inc. a federally and State-
supported community health center. Our Center serves a 10,354-square
mile rural area in northern Wisconsin with 403,964 residents, 125,229
of which have incomes at or below 200 percent of poverty. I greatly
appreciate the opportunity you've extended to me to share insights
accumulated over the last 20 years working with organized dentistry and
then building our own dental capacity in an effort to assist our State
in resolving significant oral health access problems for many of our
residents.
For most of the decade of the 1990s, I worked for change within
organized dentistry in Wisconsin. The Wisconsin Dental Association,
keenly aware of the access problems in the State's Medicaid program,
convened a committee to explore ways to resolve access problems and
enable more of our State's dentists to participate in the Medicaid
program. They extended an invitation to me to serve on that committee
as the only non-dentist in order to get the perspective of a community
health center director. At the time, there was no lack of passion or
commitment from the committee members. Wisconsin's Medicaid office
staff were most helpful in streamlining some of the administrative
impediments to greater dentist participation, and during the time of my
tenure on the committee we were successful in obtaining an increase in
State Medicaid rates. However, in spite of all these efforts, problems
persisted and, following passage of the State Child Health Improvement
Act and an annual stagnation in dental payment rates, access problems
grew worse.
In September 2001, shortly after the Surgeon General's report on
the oral health of the Nation, my board faced the prospect of continued
deterioration in access to oral health services for our Medicaid and
uninsured patients. They directed staff to prioritize solving the oral
health access and disparity problems throughout our extensive rural
service area. As staff set about the task of fixing the system, we
studied the problems more closely, which eventually led us to a
question. How do we solve a problem that is pervasive at the State and
national level? From a health center perspective the answer to this
question is one community at a time. So that is what we set about
doing. Our State welcomed our involvement as did our major partner,
Marshfield Clinic. An expanded State rural dental clinic grant program
provided us with resources to build our first dental center in 2003.
Family Health Center has had a long-term partnership with
Marshfield Clinic, relying on, rather than duplicating some of its core
infrastructure. While Marshfield Clinic is a large regionalized health
system with most specialties in medicine represented, they like many
other health systems lacked any dental health professionals. Given
their size, reputation, and our desire to promote the integration of
dentistry and medicine, Family Health Center approached Marshfield
Clinic to partner with us on our dental initiative. We provided them
with information on what amounted to a public health crisis in
Wisconsin affecting many Clinic and Family Health Center patients, and
suggested that together we could have a much larger impact on the
problem throughout our collective service area than our organization
could do on its own. Recognizing the scope of the problem, Marshfield
Clinic leadership unanimously voted to lend its infrastructure and
later additional funding in support of our initiative to reduce oral
health disparities throughout the region. This Marshfield Clinic
decision enabled the rapid expansion of our dental system which by
October 1, 2013, will also include a 9th dental clinic on Ho-Chunk
Nation land near Black River Falls, WI.
Because of State taxpayer investment in our program and also
because of strong evidence that literally tens of thousands of
Wisconsin residents were going to emergency rooms every year for
treatment of non-traumatic dental pain, we committed to caring for
patients with emergency dental conditions from across the State. Figure
1 demonstrates that from the provision of our first dental service in
temporary facilities in November 2002 through June 2013 we have cared
for 95,535 unique patients. Strikingly, they have come from every one
of Wisconsin's counties and from 73 percent of its zip code areas. We
have treated patients from Wisconsin's largest cities who traveled, in
some cases hundreds of miles, to get to a dental center in communities
as small as Neillsville with a population of 2,443. Patient origin
maps, like that of Figure 1, both illustrate the breadth and scope of
the dental access problem in Wisconsin as well as provide us with
information about communities in need. In essence, the underserved
population's care seeking patterns inform us where we should consider
placing our next dental center.
To illustrate this point, we observed that within the first 15
months of opening our Park Falls dental center, 1,000 patients had
driven an estimated 412,000 miles to receive their dental care there
from us. Many of these patients were traveling from the community of
Rhinelander, which is 67 miles from Park Falls. We investigated this
pattern with Rhinelander community leaders, including the mayor, and
learned we were only seeing the tip of the iceberg as many people in
need couldn't make the trip. A few years later we were able to open our
8th dental center in Rhinelander bringing quality dental services
closer to many of our patients and offering an opportunity for dental
care to many others who previously couldn't make the trip.
Our progress, and that of my health center colleagues in Wisconsin,
has been spurred on by increased investment of State resources in the
State rural dental clinic program, and through a doubling of our
State's community health center grant. Our State grant focuses on
supporting the mission of all of Wisconsin's 17 community health
centers. This investment has paid huge dividends for State residents
through greatly expanded access to dental care as shown in Figures 2
and 3, which mark the progress and growth of Wisconsin's community
health center dental facilities, patients served, and patient visits.
The dramatic progress of Wisconsin's health centers in expanding
oral health access to a growing number of Wisconsin residents is echoed
in the steady progress health centers across the Nation have made in
both incorporating oral health services into their programming and
increasing the proportion of their patients who receive oral health
services. In 2011, 78 percent of community health centers offered
dental services at at least one site. This compares to Healthy People
2020's baseline of 75 percent from 2007 with a nationally established
target of 83 percent by 2020. The number of patients receiving dental
services at health centers grew from 1.4 million in 2001 to over 4.0
million in 2011, a 186 percent increase. Although this represented 20
percent of total health center patients, more work remains to be done
to meet the national goal of 33.3 percent of such patients by 2020.
There is robust evidence that health centers stand ready to do this
work as reflected in the fact that more than 300 health centers applied
for funding to meet identified unmet dental needs in 2011.
Unfortunately, a last minute budget deal to keep the Federal Government
running that year included a $600 million cut to planned health center
funding. As a result, none of the 300 applications were funded. Since
then, there have been no subsequent Federal funding opportunities for
dental expansion for health centers due to limited appropriations.
Indeed, there have been no funding opportunities period for existing
health centers to expand their services since the Recovery Act. While
this was disappointing, our resolve is strong. The health center
community is ready, willing and able to leverage investments from our
States and Congress to meet State and national goals. Our integrative
approach to health care can create offsetting savings by substituting
quality dental services for more expensive emergency room and/or
hospital-based treatments that now result from current access barriers.
As the rest of my testimony will demonstrate, our approach can also
improve health and indeed, save lives.
As the preface to the Surgeon General's report stated,
``those who suffer the worst oral health are found among the
poor of all ages with poor children and poor older Americans
particularly vulnerable . . . Individuals who are medically
compromised or who have disabilities are at greater risk for
oral diseases and in turn oral diseases further jeopardize
their health.''
Our early experience confirmed the wisdom of this statement. At our
ribbon cutting for our second dental center I read a short email to
those in attendance. The author of the email reported things were going
well, that they were grateful there was a dental clinic that would take
their residents, and they were working on arrangements to send us some
more patients. What made this short email remarkable was that the
author was making arrangements to send his developmentally disabled
residents to our dental center, which was 183 miles away.
We quickly learned that accessing dental services for those with
significant developmental or cognitive disabilities was even more
difficult than the barriers faced by many low-income uninsured or
publicly insured residents. Understanding the difficulties many
disabled residents face in obtaining oral health services in our State,
we entered into a Memorandum of Agreement with our State that in
essence said ``we are open to and welcome the State's disabled
population.'' Beginning with our second dental center, each dental
center has been equipped with large treatment rooms and a wheelchair
lift to help accommodate this high need population.
We learned other lessons that surprised us. Local county Veteran's
Affairs officers informed us that low-income vets uninsured for dental
care had great difficulty accessing care. We learned that VA benefits
extended to those who are 100 percent service disabled and that a State
program provided some help, but many dentists did not participate in
the program because of paperwork issues. We learned that one of the
largest constituent complaints voiced to local legislative offices was
the inability to get dental care, and we learned that many elderly were
foregoing care because of its cost. When we build a dental center and
open our doors, our local legislators report that the phones fall
silent regarding complaints on access to dental care. Our vets, the
disabled, and the poor of all ages have a place to go. Access to dental
care is no longer the issue it once was. The health center model leaves
no one behind.
It is our belief that any organization that accepts Federal or
State taxpayer funds has a huge stewardship responsibility and a
requirement to be accountable for the expenditure of funds. One of the
ways we try to be accountable is to look for targets of opportunity to
add value. To avoid increased emergency room use for non-traumatic oral
pain, we work in many emergency patients from all over the State on a
daily basis at all of our dental centers. We also believe one of the
best services we can provide to our State is to assist our patients in
leaving the Medicaid program altogether through job attainment or job
promotion. To achieve this goal we accept referrals of job seekers from
job placement agencies. Many individuals being retrained for
predominantly service sector jobs have a difficult time getting hired
or promoted if they have significant oral health problems. We eagerly
accept such referrals in the hope that we increase such individuals'
opportunities to achieve gainful employment or promotion and leave
Medicaid in favor of private employment-based insurance. In addition we
have historically prioritized low-income pregnant women. The reason for
this is evidence that periodontal disease may contribute to poorer
birth outcomes. While the scientific community is still debating this
topic, for the sake of these unborn children, we prefer to do
everything possible that might help lead to a better birth outcome.
We have made demonstrable progress. As Figure 4 shows, while
Wisconsin was second to last in 2008 among all States in children on
Medicaid who received a dental service, the three counties with our
dental centers had access rates equivalent to those in the Nation's top
performing States. Unfortunately we are far from declaring victory. Our
accountabilities to our supporters, including taxpayers and the
communities we serve, demand that we do more to generate societal
savings to help offset the cost of dental care to those who previously
went without that care. What are our options to do better?
There is a tremendous prevention potential in dentistry. We believe
there is also a tremendous potential to improve health and reduce costs
overall if we can bridge the chasm that exists between medicine and
dentistry. We believe the bridge is through closer integration of
medicine and dentistry using 21st century technology that can support
virtual teaming between our health professionals and their staffs, and
through practice changes that reinforce shared professional interests
in patients and their health. We have begun acting on these beliefs and
received support from like-minded partners. To this end I wish to
acknowledge the significant support we have received from Delta Dental
of Wisconsin in helping us create an integrated medical/dental
electronic record to provide a platform to allow virtual teaming on
patients. Delta Dental of Wisconsin has also provided support for oral
health research and education initiatives at Marshfield Clinic's
Education and Research Divisions. I also wish to acknowledge the
DentaQuest Foundation for their support in helping us learn about best
practices for engaging our patients with diabetes and encouraging them
to seek regular dental care.
We have come to the conclusion that to get to a preferred future we
have to fundamentally change how we view dentistry within the larger
health care system. To illustrate this point, let's consider a series
of questions involving dermatology, a specialty that deals with
problems of the skin:
Why do we think we can afford adult dermatology in our
Nation's Medicaid program but not adult dental? Why is it that
we don't have separate dermatology insurance like we do for
dental insurance? Why is it that we include dermatological care
in our medical records but not dental care? Why do most medical
care systems, many who tout most if not all medical
specialties, exclude dentistry? Why do medical schools teach
our future physicians to be concerned about infections anywhere
in the body but the oral cavity? Why in Wisconsin, in spite of
very low payment rates to physicians and dentists, do most
physicians continue to treat Medicaid patients while most
dentists do not?
Other policy-oriented examples are the exclusion of dental benefits
in Medicare and the limitations on dental benefits in the VA. A more
recent example is the promotion of ``primary care medical homes'' a
terminology that excludes dental. Why not ``primary care health homes''
which is a much more inclusive concept? (Incidentally, most federally
qualified health centers would rightly consider themselves to be
integrated primary care health homes). The separate and stark contrast
between dentistry and medicine beginning with training and continuing
through insurance and practice policies should increasingly be
questioned in light of a growing body of scientific evidence linking
oral and systemic health.\1\
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\1\ Powell V, Din F, Acharya A, et al., Project on Clinical Data
Integration Page 20, Contact points between medical and dental care/
research--Version J: Categories (1-29) and references).
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Everyone is united in wanting our country to derive even more value
from our health care system, with better quality at a lower price
point. If that is the case, then why is there such reluctance to act?
We can debate whether we can afford to have dental benefits covered
under our Medicare program or whether all States should offer dental
benefits to adults in their Medicaid programs. But if cost is the
central issue holding us back, if cost is the driver in much of our
decisionmaking, why don't we act to lower costs when an evidence-base
outlining on how it could be done exists? Consider the following. As a
nation we fund medical research through the National Institutes of
Health. That societal investment has helped us understand that
connections exist between diabetes and periodontal disease and to treat
one without treating the other does have health and cost consequences.
(Please refer to Attachment 1 for a concise summary of some evidence
regarding periodontal disease and diabetes.) The value of our
investment in research to our Nation's taxpayers is magnified when we
put the results of that research into practice.
The private sector has responded and is attempting to leverage this
knowledge: the public sector should as well. What seems to have driven
the private sector to act was the emerging evidence, mostly from the
past 10 years, that individuals with selected chronic health conditions
or combinations of them benefit from improved oral health, specifically
improved periodontal status, and that potentially large reductions in
medical care costs associated with their chronic condition(s) follow
closely and appear to be sustainable as long as good oral health is
maintained. The emerging evidence appears strongest for individuals
with diabetes (only) or in combination with cardiovascular disease,
kidney disease or congestive heart failure. Savings of approximately 10
percent annually for individuals with diabetes receiving periodontal
care were reported in a multi-year Michigan Blue Cross Blue Shield
study. That study also found annual medical cost reductions ranging
from 20-40 percent for individuals with diabetes and at least one other
chronic condition previously noted.\2\
---------------------------------------------------------------------------
\2\ http://www.bcbsm.com/pr/pr_08-27-2009_71090.shtml.
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A 2006-8 CIGNA study of 46,094 individuals with diabetes estimated
annual medical cost savings of $2,483/person (23 percent) in year 3 for
those who received dental care. Notably, study results suggested
increasing annual cost savings as a function of continuing better oral
health among those individuals with diabetes that received periodontal
care at baseline (2006) and continued maintenance oral health care
annually compared to those individuals that did neither.\3\
---------------------------------------------------------------------------
\3\ Jeffcoat M, et al. CIGNA, Does Treatment of Oral Disease Reduce
the Costs of Medical Care? Medscape Today. October 19, 2011. On-line:
http://www.medscape.com/viewarticle/751609.
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United Concordia and Highmark, Inc. reported average medical care
cost savings of $1,814 per year over 3 years for individuals with
diabetes who sought periodontal treatment and subsequent regular dental
care during the 2007-9 study compared to individuals with diabetes who
did not receive dental care during the study period. Another important
study result was additional estimated cost savings of $1,477 per person
per year among individuals with diabetes after they completed seven
periodontal treatments and/or oral health maintenance visits. In
subsequent analyses that examined the relationships between gum disease
and other medical conditions, annual medical cost savings from reduced
hospitalization and office visits associated with periodontal treatment
were found for heart disease ($2,956), cerebrovascular disease
($1,029), rheumatoid arthritis ($3,964) and pregnancy ($2,430).\4\
---------------------------------------------------------------------------
\4\ https://secure.ucci.com/ducdws/dental.xhtml?content=dhc-
conditions&s1=ucwellness-oral-health-study&s2=results-ucwellness-oral-
health-study.
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A recent study in an HMO population provides further insight into
the potential sources of savings associated with better oral health
status among individuals with diabetes. Diabetes-specific hospital
emergency department visits rates were more than 60 percent higher
(16.2 percent vs. 10.1 percent) and diabetes-related hospitalization
rates were more than 75 percent higher (14.8 percent vs. 8.3 percent)
among individuals with diabetes who did not seek dental care compared
to individuals that had two or more periodontal or prophylactic
treatments annually for 3 years.\5\
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\5\ Mosen D, Pihlstrom D, Snyder J, Shuster E. Assessing the
association between receipt of dental care, diabetes control measures
and health care utilization. JADA January 2012 143(1): 20-30.
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There is clear evidence that health insurers are ramping up their
oral health programs that many established in 2005-7. Several major
insurers have announced expanded oral health-related programs for their
insureds that are pregnant and those with kidney disease,
cerebrovascular (stroke) conditions, head and neck cancer and organ
transplants.\6\ Leading health insurers seem to have concluded that
supporting and even incenting better oral health access and care is
good business. It should be so for our publicly supported programs as
well. The taxpayers of this country should demand it.
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\6\ http://newsroom.cigna.com/article_display.cfm?article_id=1287.
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I urge the subcommittee to consider following the lead of these
insurers by capitalizing on our Nation's investment in the National
Institutes of Health, and institute policy changes that would enable
Medicare and Medicaid enrollees with such chronic conditions to access
appropriate high quality oral health treatments.
Another key point for the subcommittee to consider is that it is
not enough to simply establish coverage or even more dental clinics, as
many low-income Americans do not seek dental care until they have oral
pain. While addressing pain and suffering is meritorious in its own
right, avoiding that pain and suffering and more expensive treatment
interventions is our goal. The undervaluing of oral health in America
is, from our perspective, one of the greatest health literacy
challenges we have. Our health center is involved in a generational
effort to address health literacy issues that shape the current
practice among many high-risk, low-income populations. A major
initiative is needed to help convince our residents of the importance
of oral health to general health and of the importance of regular
dental checkups in maintaining good oral health. Developing more
reliable and internally consistent estimates of population access to
oral health services should be considered part of that effort. I make
this point because it appears that the proportion of children,
adolescents and adults who use the oral health care system in the past
year is actually well below what many people believe. The percent of
residents aged 2 and older who received a dental service in 2007 is
estimated by Healthy People 2020 to be 44.5 percent. Our national goal
for 2020 is 49 percent. However, widely cited estimates based on health
interview survey data using self-reported information is in the range
of 20 percentage points higher. Although such widely diverse estimates
cannot be reconciled without further work, I note that the higher
estimate is based on self-report data that requires recall on long past
events making such estimates generally less reliable than those based
on observed expenditures. I urge the subcommittee to explore this
information further as it has significant implications for dental
workforce projections, as well as understating the need to integrate
medicine and dentistry to help address the oral health literacy issue.
We must strive for a future where people better understand the
importance of daily oral hygiene, proper nutrition, and regular dental
checkups not just to their oral health but to their overall health as
well. We believe success in this effort is tied to convincing our
medical colleagues to help educate their patients on the importance of
good oral health care and regular dental checkups. This is made more
difficult by the fact that our Nation's medical schools by and large
pay little attention to the oral cavity in medical student training.
This is evidenced by the response to 2012 survey question by the AAMC
of our Nation's graduating medical students on, ``How well do you feel
that your medical school has trained you to address oral/dental health
topics?'' Apparently, students were underwhelmed as 32.4 percent of the
Nation's graduates checked ``not well trained at all'' and only 1.3
percent checked ``very well trained.'' Our vision for the future is
that our physician community treat the importance of regular oral
health checkups on a par with their counseling of patients on the need
to be immunized, receive clinical preventive services, exercise, and
eat right. In addition to the virtual teaming I mentioned earlier, our
dental teams should be aided by an integrated electronic medical
record, to engage patients on the importance of receiving clinical
preventive services in medicine. Currently we do blood pressure checks
and non-fasting blood sugars under protocols in our dental centers.
These efforts can have a direct impact on morbidity and even mortality
in our patients as evidenced by a recent message one of our hygienists
received from a dental patient:
``You know I thought that it seemed dumb that you would take
blood pressure at the dentist office until I had a friend of
mine come here and you guys took his blood pressure in hygiene
and wouldn't even see him. You sent him right over to the
emergency room. Good thing you did, they took him into
emergency surgery. I guess they said he was ready to pop.''
We should expect this type of coordination in our health care
system. Additional examples of teaming across medicine and dentistry
are provided in Attachment 2.
I'd like to conclude my testimony by sharing some observations
regarding dental workforce and dental education issues. Early on, we
recognized that to be successful in our dental initiative we could not
ignore workforce and dental education issues that might confound our
progress. Figure 5 indicates that given current rates of dental school
production, the age distribution of dentists in Wisconsin portends a
shortage of dentists. Over the next 20 years, 2.2 dentists are likely
to retire for each new dentist entering practice. As if this is not bad
enough, two factors may further aggravate the situation for northern
rural communities. First, there currently exists a marked preference of
dentists to locate in suburban or urban areas of our State relative to
the less populated communities. Second, retiring dentists are
predominantly male, while new graduates are gender balanced and female
dentists in Wisconsin have shown an even more marked preference for
suburban or urban practices. Rural Wisconsin loses on both of these. We
are hoping to meet this challenge by establishing, in partnership with
Marshfield Clinic, a dental residency program and by providing
dedicated space within our dental facilities for dental students.
As we continue to grow our dental system to enlist nearly 50
dentists in this work by years end, we can reflect on the opportunity
we have had to hire dentists trained in over a dozen dental schools
across the country. Most dental schools are urban-based and specialty-
oriented. Most provide students with less exposure than we would like
to treating developmentally disabled patients and young children.
Nationally, as I speak with my health center colleagues, not enough
graduates are interested in careers in the safety-net. Ed O'Neil,
director, UCSF, Center for the Health Professions, Center on
Recommendations for Reform (3/7/07) said it best:
``For instance, in many specific locations the Nation is
experiencing a raging epidemic of pediatric dental disease. In
face of this reality, does it make sense to prepare more young
men and women with the skills to serve the bungalow-based smile
clinics that serve the suburbs? Instead, shouldn't we align the
training with the needs of community clinics to organize and
deliver a broad range of preventative and therapeutic services
to the population that is experiencing the epidemic?''
As a nation we should not lose sight of the importance of oral
health to general health, and the importance of oral health in its own
right. What some of us take for granted is currently beyond the reach
of many. Discussions I have had with many well-educated people on the
problems lower income people face obtaining dental care usually result
in surprise. They didn't know. There is a reason the Surgeon General
referred to this problem as a ``silent epidemic.''
I thank the subcommittee for this opportunity for me to share what
we've learned and most importantly for taking up this subject, it may
still be an epidemic but let it be silent no longer.
Figure 1
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Figure 5
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Attachment 1.--A Brief Summary of the Evidence Base for Intervention to
Improve Oral Health Among Individuals with Diabetes
diabetes as a pandemic threat to oral health
Physiology does not respect the disciplinary divide that separates
the medical from the dental care of the diabetic patient. Diabetes (DM)
is a pandemic in the United States: in many counties, over 10 percent
of people over 20 years old are affected.\1\ The disease is accompanied
by wide-ranging health consequences that worsen if it is poorly
controlled. To use the legal vernacular, it is established beyond a
reasonable doubt that DM has a deleterious effect on periodontal
disease (PD) and the evidence is mounting on the impact of periodontal
health on diabetic control.\2\ The evidence supporting a link between
PD and DM is so strong that PD has been classified as the 6th
complication of diabetes.\3\ DM now affects nearly 26 million Americans
and over the next decade, an estimated 40 million more adults could
develop the condition, and its complications are expensive. Absent
changes, the surge in new cases could add an estimated $512 billion to
annual health care spending by 2021 . . . ''.\4\ In spite of this
knowledge, only 55.6 percent of the U.S. population aged 2 years and
older with diagnosed diabetes had been to the dentist in the past
year.\5\ Moreover, severe disparities exist in dental access based on
income, insurance status, educational attainment and race.
comprehensive description of the model and supporting evidence base
The Institute of Medicine (IOM), National Academy of Sciences,
released a report, ``Dental Education at the Crossroads: Challenges and
Change,'' in January 1995, calling for greater collaboration between
medicine and dentistry. The report said closer integration was needed
between dentistry and medicine on all levels of the health care system:
research, education and patient care. In 2000 Surgeon General David
Satcher's report entitled ``Oral Health in America'' was released. The
report focused attention on a national problem which had gone largely
unrecognized for decades: the oral health crisis. Dr. Satcher
emphasized that oral health does not only encompass teeth. He
underlined the importance of recognizing the integration between oral
and systemic health and the profound mutual impact that one has on the
other, stating that one cannot have systemic health in the absence of
oral health. To emphasize this point, he summarized the existing
evidence that points to important links between oral disease, such as
PD, and systemic diseases such as DM, heart disease and stroke,
respiratory health and fetal health (miscarriage and stillbirth). The
Surgeon General further exposed disproportionate access to dental
health care encountered by disparity-prone populations including low-
income individuals, those with no insurance, children, the elderly,
handicapped and institutionalized patients who experience what he
dubbed the ``silent epidemic'' when referencing the high rate of oral
disease prevalent among these populations.
The report revealed how a struggling and stagnated dental industry
that was experiencing workforce shortages exacerbated the problem by
denying access to vulnerable populations without the ability to pay
for, or access services. His report revealed how, in addition to the
systemic ramifications of poor oral health, far reaching consequences
were inflicted on those with limited or no access, including high
social and economic cost to the individual, negative impact on quality
of life and the burden this also placed on society. Importantly, the
Surgeon General emphasized that this trend was reversible and
preventable and pointed to the importance of bringing education and
research to bear on the problem as actionable ways to advance oral-
systemic health. Dr. Satcher called for further investigations into
oral-systemic health connections, health disparity research, community-
based, public health and behavioral health initiatives, health services
research, and an expansion in diagnostic and treatment options which
would emphasize proactive disease prevention. His report emphasized
that for three decades improvement in oral health had been a focus area
of U.S. Department of Health and Human Service's Healthy People
initiative and that solving the problem would require a concerted
effort between the health care industry including professionals and
health care entities, academia, the government, health insurers and
patients. Notably, 13 years later, oral health remains a priority focus
in Healthy People 2020, with many objectives remaining to be
achieved.\6\
A chasm currently exists between our perceptions, financing, and
delivery of oral health services and general medical services. It
persists despite mounting evidence that it should not. Yet today,
proportionately fewer of us annually access oral health services than
medical services. Our oral health record for some of our most
vulnerable citizens is abysmal. The elderly, where chronic disease is
more prevalent, have the lowest rate of dental insurance of any age
group.\7\ Poor children on Medicaid/CHIP have public dental insurance,
but low reimbursement rates and other problems have left most without
annual oral health services. Poor adults have even less coverage and
access.
This trail leads to an important question, ``If the future is
medical homes and ACOs, where is oral health in that calculus? Why
isn't it more prominent when evidence exists to support its inclusion
in these new models/systems.''
brief summary of the evidence base
PD is a broad term encompassing a complex disease initiated by a
variety of pathogens, largely anaerobic bacteria which establishes a
niche in dental plaque that they lay down to protect themselves from
exposure to oxygen. The disease is not a single entity and may, or may
not exhibit a familial pattern of inheritance. PD may range from its
mildest manifestation, gingivitis, a self-limited condition, to severe
periodontal disease that is associated with pain, gum erosion,
loosening of teeth (attachment loss) and bone loss below the affected
tooth and eventually, if untreated, loss of the tooth. PD may be acute
and resolve with appropriate treatment (scaling and root planing,
sometimes supplemented by antibiotic therapy, and proper oral hygiene)
or in a subset of patients, establish chronicity and refractoriness to
treatment. PD is a highly prevalent condition among adults in the
United States with an estimated 40 percent prevalence rate of moderate
to severe disease.\8\ Research examining exacerbation of systemic
disease in the presence of oral disease and vice versa has produced
substantive evidence that such connections are real.\9\ \10\ Much
research in the past two decades has explored the validity of the
``focal infection theory'' that promotes the possibility that organisms
present at a focal infection site or their products may gain systemic
access and become associated with promulgating other disease processes.
PD represents such a focal infection and risks for systemic
manifestations increase with establishment of chronicity. Of importance
here is that with proper hygiene and regular dental care and education,
this disease is largely preventable and its prevention and control
could exert considerable far reaching impact on promoting systemic
health at multiple levels.
An extensive evidence base exists to support the reintegration of
the mouth into the body for everyone.\11\ The impact of DM on PD was
recognized nearly 50 years ago \12\; Moreover, mounting evidence
substantively supports mutual bidirectional exacerbation of these two
conditions.\13\ \14\ \15\ In a systematic review of 48 studies
undertaken since the 1960s, 44 studies reported increased prevalence,
extent, severity or progression of PD in patients with DM.\16\
Interestingly, the observation by two independent studies in 1989 \17\
\18\ reported that infectious processes can establish insulin
resistance in non-diabetics that can persist for 3 months following
resolution of the infectious process, promoted the concept that PD also
contributes to diabetic status. Notably, PD is also a risk factor for
stimulating diabetes-associated complications.\19\ \20\ \21\ Adjusted
for other risk factors, mortality risks related to ischemic heart
disease and diabetic nephropathy were 2.3 and 8.5 times higher,
respectively, for individuals with DM and severe PD compared to those
with no PD; overall mortality risk from cardio-renal pathology was 3.5
times higher for those with DM and PD compared to subjects with no
PD.\20\
The mechanism underlying this bacterial impact on glycemic control
is attributed to dysregulation of insulin-mediated glucose uptake at
the skeletal muscle level, inducing a state of systemic insulin
resistance.\22\ Studies among Pima Indians with a high rate of DM \23\
and in a population of Japanese patients with DM \24\ strongly suggest
that DM is a risk factor for PD, likely due to increased susceptibility
of diabetic patients to infectious processes due to compromised
immunocompetence related to irreversible formation of advanced
glycation end products. Proteins mediating immunological functions
become compromised due to non-enzymatically mediated glycation and
multiple pathological mechanisms converge to induce what manifests as a
heightened chronic proinflammatory state that simultaneously
exacerbates both the DM and PD pathophysiological processes.\22\ \25\
\26\ Chronic systemic micro-inflammatory processes have been implicated
as a common factor underlying both DM and PD, driving chronicity,
progression and mutual exacerbation of these conditions in the absence
of intervention. Importantly, micro-inflammatory processes which
contribute to disease chronicity appear to be modifiable risk factors
responsive to PD treatment and regular dental care as well as more
advanced therapeutic regimes.\27\
Poor glycemic control is an important factor in PD progression and
severity.\28\ \29\ Notably, outcomes of four recent systematic reviews
and meta-analyses support the position that glycemic control improves
periodontal health, and, conversely, improvement in periodontal health
impacts positively on glycemic control. \30\ \31\ \32\ \33\ \34\
Collectively, these results strongly support potential for simultaneous
stemming of epidemic prevalence of both PD and DM through cross
disciplinary efforts that systematically target glycemic control and
good oral care. Promoting interdisciplinary care processes is pivotal:
studies evaluating dentists' understanding of DM-PD bi-directional
relationship showed that 60 percent promoted this with patients;
physician awareness of PD/DM complications was low.\34\ Strikingly,
interactions between dentists and physicians on oral-systemic patient
management were measured at <15 percent in a 2006 U.S. study.\35\
References
1. Centers for Disease Control and Prevention. National Diabetes
Surveillance System. 2009 [cited 2013 April 02]; Available from: http:/
/apps.nccd.cdc.gov/DDTSTRS/default.aspx.
2. Taylor, G.W. and W.S. Borgnakke, Periodontal disease:
associations with diabetes, glycemic control and complications. Oral
Dis, 2008. 14(3): p. 191-203.
3. Loe H. 1993. Periodontal disease. The sixth complication of
diabetes mellitus. Diab Care 16:329-34.
4. Vojta D, De Sa J, Prospect T, Stevens S, Effective Interventions
for Stemming the Growing Crisis of Diabetes and Prediabetes: A National
Payer's Perspective. Health Affairs, 31, No 1 (2012): 20-6.
5. Healthy People 2020, Summary of Objectives, Diabetes, D-8,
Annual dental examinations.
6. Koh, H. 2010. A 2020 vision for Healthy People. NEJM 362: 1653-
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7. MEPS Chartbook No. 17, Dental Use, Expenses, Dental Coverage,
and Changes, 1996 and 2004, AHRQ, DHHS.
8. Fuster V, Badimon L, Badimon JJ, 1992. The pathogenesis of
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9. Kim J and Amar S. 2006 Periodontal disease and systemic
conditions: a bidirectional relationship. Odontol 94: 10-21.
10. Pizzo G, Guiglia R, Lo Russo L, Campisi G. 2010. Dentistry and
internal medicine: from the focal infection theory to the periodontal
medicine concept. Eur J Internal Med 21: 496-502.
11. Powell V, Din F, Acharya A, et al., Project on Clinical Data
Integration Page 20, Contact points between medical and dental care/
research--Version J: Categories (1-29) and references.
12. Belting SM, Hiniker JJ, Dummett CO. Influence of diabetes
mellitus on severity of periodontal disease. J Periodontol 1964 35:476-
80.
13. Mealey BL, Rose LF. Diabetes mellitus and inflammatory
periodontal diseases. Curr Opin Endocrinol Diabetes Obes. 2008;15:135-
41.
14. Taylor GW, Borgnakke WS. Periodontal disease: associations with
diabetes, glycemic control and complications. Oral Dis. 2008;14:191-
203.
15. Nagasawa T, Noda M, Katagiri S, Takaichi M, Takahashi Y, Wara-
Aswapati N, Kobayashi H, Ohara S, Kawaguchi Y, Tagami T, Furuichi Y,
Izumi Y. Relationship between periodontitis and diabetes--importance of
a clinical study to prove the vicious cycle. Intern Med. 2010;49:881-
85.
16. Taylor GW, Burt BA, Becker MP, Genco RJ, Schlossman M, Knowler
WC. 2001 Severe periodontitis and risk for poor glycemic control in
patients with non-insulin dependent diabetes mellitus. J Periodontol
67: 1085-93.
17. Sammalkorpi K. 1989. Glucose intolerance in acute infections. J
Int Med 225: 15-19.
18. Yki-Jarvinen H, Sammalkorpi K, Koivisto VA, Nikkila EA. 1989
Severity, duration and mechanisms of insulin resistance during acute
infections. J Clin Endocrinol Metab 69: 317-23.
19. Jepsen S, Kebschull M, Deschner J. Relationship between
periodontitis and systemic diseases. Bundesgesundheitsblatt
Gesundheitsforschung Gesundheits
schutz. 2011;54:1089-96.
20. Saremi A, Nelson RG, Tulloch-Reid M, et al. Periodontal disease
and mortality in type 2 diabetes. Diabetes Care 2005;28:27-32.
21. Shultis WA, Weil EJ, Looker HC, Curtis JM, Shlossman M, Genco
RJ, Knowler WC, Nelson RG. Effect of periodontitis on overt
nerphropathy and end-stage renal disease in type 2 diabetes. Diabetes
Care. 2007 30: 306-11.
22. Grossi SG, Genco RJ. 1998. Periodontal disease and diabetes
mellitus: a two-way relationship. 3: 51-61.
23. Nelson RG, Shlossman M, Budding LM, Pettitt DJ, Saad MF, Genco
RJ, Knowler WC. 1990 Periodontal disease and NIDDM in Pima Indians
Diabetes Care. 13: 836-40.
24. Nishimura F, Kono T, Fujimoto C, Iwamoto Y, Murayama Y. 2000.
Negative effects of chronic inflammatory periodontal disease on
diabetes mellitus. J Int Acad Periodontol. 2: 49-55.
25. Genco, R.J., Glurich, I., Haraszthy, V., Zambon, J., DeNardin,
E. 1998. Overview of Risk Factors for Periodontal Disease and
Implications for Diabetes and Cardiovascular Disease. Compendium of
Continuing Education in Dentistry (Symposium Proceedings) 19: 40-4.
26. Collin, HL, Uusitupa M, Nisanen L, Kontturi-Narhi V, Markkanen
H, Koivisto AM. 1998, Periodontal findings in elderly patients with
non-insulin dependent diabetes mellitus. J Periodontol 69: 962-66.
27. Lalla E and Papapanou PN. Diabetes mellitus and periodontitis:
a tale of two interrelated diseases. Nat Rev Endocrinol 2011 Jun 28
Epub ahead of print.
28. Weidlich P, Cimoes R, Pannuti CM, Oppermann RV. Association
between periodontal diseases and systemic diseases. Braz Oral Res.
2008;22 Suppl 1:32-43.
29. Chavarry NG, Vettore MV, Sansone C, Sheiham A. The relationship
between diabetes mellitus and destructive periodontal disease: a meta-
analysis. Oral Health Prev Dent. 2009;7:107-27.
30. Darre L, Vergnes JN, Gourdy P, Sixou M. Efficacy of periodontal
treatment on glycaemic control in diabetic patients: A meta-analysis of
interventional studies. Diabetes Metab. 2008;34:497-506.
31. Janket SJ, Wightman A, Baird AE, Van Dyke TE, Jones JA. Does
periodontal treatment improve glycemic control in diabetic patients? A
meta-analysis of intervention studies. J Dent Res. 2005;84:1154-59.
32. Simpson TC, Needleman I, Wild SH, Moles DR, Mills EJ. Treatment
of periodontal disease for glycaemic control in people with diabetes.
Cochrane Database Syst Rev. 2010:CD004714.
33. Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment
on glycemic control of diabetic patients: a systematic review and meta-
analysis. Diabetes Care. 2010;33:421-27.
34. Al-Khabbaz AK, Al-Shammari KF, Al-Saleh NA. Knowledge About the
Association Between Periodontal Diseases and Diabetes Mellitus:
Contrasting Dentists and Physicians. J Periodontol. 2011;82:360-66.
35. Kunzel C Lalla E Lamster IB. Management of the patient who
smokes and the diabetic patient in the dental office. J Periodontol
2006 77: 331-40.
Attachment 2.--Examples of the value to patients of better coordination
between medicine and dentistry
Case example: A Family Health Center patient living in Clark County
was referred to the Ladysmith Dental Center by his Marshfield Clinic
Oncologist. His cancer treatments were negatively impacting on his oral
health status, and as a result he began losing weight. The patient was
initially scheduled for an emergency visit and followup dental care.
All of his teeth needed to be extracted and he was fitted for dentures.
To date, the patient has improved oral health and has gained 10 pounds.
Case example: An elderly woman on Medicare presented at our
Ladysmith Dental Center with severe diabetes, which was not controlled
well due to the condition of her teeth. She had driven over 4 hours
one-way to get to our clinic. She had only a few teeth, which had to be
extracted. Over several visits we were able to provide her with
dentures and in a subsequent visit she reported that she is now eating
better and has her diabetes under better control.
Case example: Another diabetic patient presented at our Ladysmith
Dental Center. The patient was jaundiced and very ill and had a large
lesion on his leg for the past 4 years that would not heal. He also had
severe oral health disease. Following a full mouth extraction and
dentures, this patient has been back for routine care. He reports his
blood glucoses are under control, he has good skin color, his skin
lesion is healed and he is very happy.
Case example: A 20-year-old female with no income presented as
unemployed and depressed with very poor oral health. We provided
extractions and dentures. She now has an improved self image and a job.
Case example: A patient presented at our Ladysmith Dental Center as
an emergency. She was in high school at the time of her first visit and
she qualified for a full discount under our sliding-fee program. Due to
the extensive dental care needed and her family's inability to afford
that care, she was not able to find a dentist that would see her. Her
extensive dental care included root canals, crowns, and major fillings
in the majority of her top teeth. To date, the cost of her care exceeds
$5,000. She is now an established patient with the dental center and
the majority of the work was completed in time for her senior picture.
Case example: A teenage child with spina bifida presented to clinic
to establish care with a new pediatrician. The examination revealed
multiple severe dental caries requiring extraction and repair. This
child had just been hospitalized for many months to repair and heal her
third sacral decubitus. Pediatrician requested prompt dental treatment
to decrease the potential for additional infections that could
jeopardize skin integrity. Pediatric care coordinator and special needs
dental coordinator worked together to arrange dental treatment under
anesthesia with appropriate skin pressure relief measures in place to
prevent possible skin breakdown. Dental health was achieved, skin
integrity was maintained and potential for additional infections due to
decay and gum disease reduced. This child also had improved self-esteem
and improved social interactions with peers.
Case example: A teenage patient with special needs presented to the
pediatrician for a well-check. Patient has profound cognitive
impairment, no speech, aggressive behavior and is completely
uncooperative with examinations. Patient had previously received dental
care and treatment under anesthesia and was in need of a dental exam
with cleaning again. Pediatrician requested additional specialty care
examinations and procedures be done in conjunction with the scheduled
dental service. Pediatric care coordinator and special needs dental
coordinator were able to arrange eye exam, gynecological exam, ENT
exam, blood draw for lab testing and vaccinations to take place while
patient was anesthetized for the dental procedure.
Senator Sanders. Thank you very much, Mr. Nycz.
Ms. Stallings.
STATEMENT OF CATHI STALLINGS, MSW, FALLS CHURCH, VA
Ms. Stallings. Good morning, Chairman Sanders and
distinguished members of the subcommittee. My name is Cathi
Stallings, and I am a social worker from Falls Church, VA. I am
here as someone who knows firsthand that dental care is a
luxury that many millions of us in America cannot afford. I
have paid thousands of dollars for dental work and need much
more.
I, personally, am focused on this issue because I am not
able to afford to pay the exorbitant cost for the dental work
that I need. Since finding out the extent of my dental needs, I
have spent many dark hours wondering how I will afford my
future.
Several years ago, I took out a bank loan to pay for a
bridge that I needed. I was told a few months ago that the
bridge needs to be replaced. I was quoted the price of $7,000
for this. The periodontist said he would give me a discount,
but it didn't matter. I couldn't afford that, either.
I have quite a few other dental issues. The insurance
coverage with my job covers $1,290 per year, which doesn't
cover even one of the crowns I need, let alone anything else.
Crowns have been quoted to me up $2,000 each. In the past 2
months, I've needed scaling and root planing for gum disease,
as well as an emergency crown when one of my teeth cracked.
As a social worker, I work with severely mentally ill
clients, most of whom have not been able to afford to go to a
dentist in many years. One issue for them is that numerous
medications cause dry mouth, but with psychotropic medications,
there can be a more severe effect, as it usually takes more
than one medication to treat the mental health symptoms. Saliva
helps in preventing dental pathologies, like cavities and gum
disease, by the cleansing and antibacterial action.
One of my clients has very few teeth left. He found out 2
weeks ago that he has three abscesses in his remaining teeth.
His Medicaid benefits only provide extractions of teeth, but no
dental services. If more of his teeth are pulled, he said he
doesn't know how he'll be able to eat.
Another one of my clients receives general relief funds of
$220 per month to live on. I gave her information about a
dentist who was providing a free emergency exam and x-rays. She
went and found out that she needs scaling and root planing for
her gum disease. The total price that was quoted to her for
this procedure was $1,600. I then directed her to a lower cost
dental service this summer, and she was told that they may have
an opening in November, since there is such a long waiting
list.
This week, I was told by another client that he was told in
1999 that he had 11 cavities. He has never been treated for any
dental work in all these years. He said, ``I guess I'm on my
way to a root canal, because I do feel a sensation in my
mouth.''
I had an extremely unusual birthday this year. As I was
preparing to go out and celebrate with my mother, I heard on
the news about the Maryland Mission of Mercy clinic, where free
dental services were being provided. Immediately, I ran out of
my home, met my mom outside and told her, ``We have to cancel
my birthday. I have to go to Laurel, MD.''
We went and were told they were full for the day, but that
I could try again tomorrow. I knew that dental care was much
more crucial than celebrating my birthday. So that evening, I
went back to Laurel and arrived around 8 p.m. I was No. 2 in
line. I was thinking that I wish I could have brought all my
clients with me.
Many others started to show up as time went on. We shared
our stories of dental nightmares. I spent the night on the
sidewalk, but I didn't mind, because I was getting a great
birthday gift. It turns out that the gift was seeing over 400
volunteers in action, giving their time and hearts to provide
over $750,000 worth of free dental work that weekend.
I wasn't able to get the dental services I was hoping for,
as they weren't able to do specifically what I needed. But I
came away with a scene that I will never forget--men and women
of every race, creed, and color lined up for what seemed like a
mile, in dire need, with the hope of being helped. It was truly
heart-breaking for me to see.
I have learned that the lack of adequate dental care can
lead to diabetes, chronic heart disease, and strokes. These
risks are scary for me and so many others. But you have the
solution in your hands.
I am a social worker. These are my clients. But on this
issue, all of us are standing together in the same line,
looking for help. I beg you to pass this legislation so that
help can be provided to all.
Thank you for your valuable time and attention to this
critical matter.
[The prepared statement of Ms. Stallings follows:]
Prepared Statement of Cathi Stallings, MSW
Good morning Chairman Sanders and prestigious members of the
subcommittee. I appreciate the opportunity to speak before you today.
My name is Cathi Stallings, and I am a social worker from Falls Church,
VA.
I am here as someone who knows firsthand that dental care is a
luxury that many millions of us in America cannot afford. I have paid
thousands of dollars for dental work and need thousands more.
I personally am focused on this issue because I am not able to
afford to pay the exorbitant cost for the dental work that I need.
Since finding out the extent of my dental needs, I have spent many
dark hours wondering how I will afford my future. Several years ago I
took out a bank loan to pay for a bridge that I needed. I was told a
few months ago that that bridge needs to be replaced. I was quoted the
price of $7,000 for this, but the periodontist said he would give me a
discount.
I have quite a few other dental issues. The insurance provided with
my job covers only $1,290 per year, which does not cover even one of
the crowns I need, let alone anything else (they have cost me about
$2,000 each). In the past 2 months, I've needed scaling and root
planing for gum disease, as well as an emergency crown when one of my
teeth cracked.
As a social worker, I work with severely mentally ill clients, MANY
of whom have not been able to afford to go to a dentist in years.
Numerous medications cause dry mouth, but with psychotropic medications
there can be a more severe effect, as it usually takes more than one
medication to treat the mental health symptoms. Saliva helps in
preventing dental pathologies, like cavities and gum disease, by the
cleansing and antibacterial action.
One of my clients has very few teeth left. He found out 2 weeks ago
that he has three abscesses in his remaining teeth. His Medicaid
benefits provide only extractions of teeth--no dental services. If more
of his teeth are pulled, it will become increasingly difficult for him
to eat.
Another one of my clients receives General Relief funds of $220 per
month to live on. I gave her information about a dentist who was
providing a free emergency exam and x-rays. She went and found out that
she needs scaling and root planing for her gum disease. The total price
quoted to her for this procedure was $1,600. I then directed her to a
lower cost dental service this summer, and she was told that they may
have an opening in November, since there is such a long waiting list.
Every day my clients pay for the consequences of their illness and
their inability to support themselves.
I had an extremely unusual birthday this year. As I was preparing
to go out and celebrate with my mother, I heard on the news about the
Maryland Mission of Mercy clinic, where free dental services were being
provided. Immediately, I ran out of my home, met my mom outside and
told her, ``We have to cancel my birthday. I have to go to Laurel,
MD.''
We went and were told they were full for the day, but that I could
try again tomorrow. I knew that dental care was much more crucial than
celebrating my birthday. So that evening, I went back to Laurel and
arrived around 8 p.m. I was No. 2 in line.
Many others started to show up as time went on. We shared our
stories of dental nightmares. I spent the night on the sidewalk, but I
didn't mind, because I was getting a great birthday gift. It turns out
that the gift was seeing over 400 volunteers in action giving their
time and hearts to help give over $750,000 worth of free dental work
that weekend.
I wasn't able to get the dental services I was hoping for, as they
weren't able to do specifically what I needed. But I came away with a
scene that I will never forget--men and women of every race, creed and
color lined up for what seemed like a mile--in dire need, with the hope
of being helped. It was truly heart-breaking for me to see.
I have learned that the lack of adequate dental care can lead to
diabetes, chronic heart disease and strokes. These risks are scary . .
. for me and so many others. But YOU have the solution in your hands.
I am a social worker. These are my clients. But on this issue ALL
of us are standing together in the same line, looking for help.
I beg you to pass this legislation so that help can be provided.
Thank you for your valuable time and attention to this critical matter.
Senator Sanders. Ms. Stallings, thank you very much.
Dr. Hughes.
STATEMENT OF DEBONY R. HUGHES, D.D.S., PROGRAM CHIEF, DENTAL
HEALTH PROGRAM AND DEAMONTE DRIVER DENTAL PROJECT, PRINCE
GEORGE'S COUNTY HEALTH DEPARTMENT, CHEVERLY, MD
Ms. Hughes. Good morning. I am a public health dentist. As
Senator Sanders stated, I began my career in public health 21
years ago in Vermont, and for the past 7 years, I have been the
program chief of the dental health program for Prince George's
County Health Department. Last fiscal year, we provided more
than 3,200 clinic visits to children and pregnant women.
In addition, we provide oral health education across the
county and work with community organizations. Working with
patients, clinicians, health administrators, and community
organizations has given me insight on the state of oral health
both locally and nationally.
I would like to thank Chairs, Senator Sanders and Senator
Burr, and committee members for this opportunity to share
information about the climate and landscape of dental access
and cost issues in my jurisdiction.
Let me begin by telling you about some experiences that
influence my remarks today and inspire my work. In Vermont, I
lived in a small town with a population of approximately 8,000,
and there were four private dental offices. At that time,
Vermonters eligible for Medicaid did not have access to any of
those four dental offices.
With the help of a community organization, we were able to
provide care and expand access to Medicaid-eligible residents.
In Prince George's County, the Health Department provides a
similar safety net for dental care.
Recently, I participated in my first Mission of Mercy. This
2-day, large-scale event provided free dental care to uninsured
adults. Men and women camped out overnight, waiting to be
served. Many received quality care, but patients should not
have to endure such conditions to receive treatment.
This experience affirmed my belief that dental care is not
a luxury, but rather a necessity, and we must make it
accessible to all adults. But achieving this goal will be
difficult if we are unable to address rising operational costs
of dentistry.
Of course, we cannot talk about the high cost of dentistry
without acknowledging the cost of dental education. It's not
uncommon for a dentist to graduate with a debt of over
$200,000, and, arguably, education costs play a role in access
and driving cost.
But operating a practice is the true cost driver. For
example, building out a dental office can cost up to $500,000
for equipment alone. Coupled with the escalating costs of staff
salaries, insurance premiums, dental supplies, laboratory fees,
and equipment upkeep, which are largely unknown to those
outside the field of dentistry, a practice can experience
staggering costs. My clinic recently had repairs on an x-ray
unit, and the labor fee alone was $295.00 per hour.
For many consumers who have neglected their dental care,
extensive treatment is often required, and it can be expensive.
For example, according to the American Dental Association's
2011 survey of dental fees in the South Atlantic Region, the
average cost of a root canal is $1,075. Add in the cost of a
crown, and the fee increases an additional $1,079.00. Of
course, the less expensive option is to have the tooth pulled,
but this choice can lead to problems with chewing, speech, and
appearance.
Can dental costs be contained? This is a question I cannot
answer. But it is important for consumers to know what drives
their cost. As a public health dentist, I think about
education, prevention, outreach, and obtaining more resources
to provide increased accessibility to care.
In Prince George's County, there is an established mobile
health fleet that provides medical and dental care to public
schools. The county health department operates the Deamonte
Driver Dental Project, which is a mobile dental unit funded by
the Maryland Office of Oral Health, providing care to children.
We address the emergent needs and provide resources for
families to establish a dental home. We work with volunteer
dentists in the neighborhoods of the schools we service to
provide a resource for families that will continue the efforts
to make dental care easily accessible.
Last fiscal year, the project provided care to more than
2,300 children on a budget of $180,000. Mobile units are not a
panacea for treatment, but they are certainly a model for
providing affordable dental care.
Prevention is an important aspect of reducing costs for
dental treatment. After the death of Deamonte Driver, Governor
O'Malley assembled the Dental Action Committee. One of the
recommendations was to institute school-based oral health
screenings program. The Maryland Dental Action Coalition,
formed from the original Dental Action Committee, received
$172,000 from the Kaiser Foundation to develop a demonstration
project to determine the feasibility of this type of program in
Prince George's County.
The results of the project showed that it is vital to have
a presence in the schools. Of 3,000 children screened, 200 were
in the A category, potential Deamonte Drivers, which indicated
that they had an immediate need, either infection or multiple
decayed teeth.
It is these types of programs that will address affordable
accessibility. We need a stronger financial commitment to
support the public health infrastructure so that the dental
needs of all Americans can be met.
Thank you again for the opportunity to address this crisis.
[The prepared statement of Ms. Hughes follows:]
Prepared Statement of Debony R. Hughes, D.D.S.
Good morning. My name is Dr. Debony Hughes and I am a public health
dentist. I began my career in public health 21 years ago in Vermont and
for the past 7 years I have been the Program Chief of the Dental Health
Program for Prince George's County Health Department in Maryland. Last
fiscal year, we provided more than 3,200 clinic visits to children and
pregnant women. In addition we provide oral health education across the
county and work with community organizations. Working with patients,
clinicians, health administrators and community organizations has given
me insight on the state of oral health both locally and nationally.
I would like to thank chairs Senator Sanders and Senator Burr and
committee members for this opportunity to share information about the
climate and landscape of dental access and costs issues in Prince
George's County.
Let me begin by telling you about some experiences that influence
my remarks today and inspire my work in Prince George's County.
In Vermont, I lived in a small town with a population of
approximately 8,000 and there were four private dental offices. At that
time, Vermonters eligible for Medicaid did not have access to any of
those four dental offices. With the help of a community organization,
we were able to provide care and expand access to Medicaid eligible
residents. In Prince George's County, the Health Department provides a
similar safety net for dental care.
Recently, I participated in my first Mission of Mercy, a large-
scale event providing free dental care to uninsured adults. For 2 days
dental professionals treated hundreds of adults each day. I was
overwhelmed to see so many amassed to receive treatment. People slept
overnight in hopes to receive care. Many received quality care but I
believe patients should not have to endure those types of conditions to
receive treatment.
These experiences reminded me that quality dental care is not a
luxury, it is a necessity and we need to make it accessible and
affordable for adults to receive the care they need and deserve.
These experiences also tell me that this task will remain difficult
if we are unable to address the escalating costs of dental education
and the escalating operational costs of dentistry.
There are several factors that influence the correlation of dental
insurance coverage and utilization, access to care, and high costs of
dental care which leads to more extensive and expensive treatments.
Providing dental care is costly. When we talk about the high cost
of dentistry, we need to look at the several aspects of care. First,
let us consider the costs of a dental education. It is not uncommon for
dentist to graduate with a debt of over $200,000. Establishing an
office can cost up to $500,000 for equipment alone. The escalating
costs of staff salaries, insurance premiums, dental supplies,
laboratory fees and equipment upkeep are staggering and largely unknown
to those outside the field of dentistry. Our clinic recently had a
repair done on an X-ray unit. The labor fee alone was $295.00 per hour.
For many people who have neglected their dental care for a variety
of reasons, extensive treatment may be required. For example, a root
canal, a procedure that requires removing the infected nerves in the
root of a tooth can cost on average, of $1,075 according to the
American Dental Association's 2011 Survey of Dental Fees in the South
Atlantic Region. This fee does not include the cost of the crown, which
averages $1,079.00. The less expensive option is to have the tooth
pulled which can lead to other problems that can affect chewing, speech
and appearance.
With these types of exorbitant costs to maintain a quality
practice, the costs for dental procedures have to stay competitive with
the supporting costs of the practice. Can these costs be contained? I
am not in the position to answer this but it is important for consumers
to know what drives the costs in dentistry.
As a public health dentist, I think about education, prevention,
outreach and obtaining more resources to provide increased
accessibility to care. In Prince George's County, there is an
established mobile health fleet that provides medical and dental care
to the public schools. The county health department operates the
Deamonte Driver Dental Project (DDDP), which is a mobile dental unit.
This project honors the legacy of Deamonte Driver by providing dental
care to Title I schools, which includes the school he attended. The
project, funded by the Maryland Office of Oral Health, allows us to
provide care to insured and uninsured children. We address the emergent
needs and provide resources for families to establish a dental home. We
work with volunteer dentists in the neighborhoods of the schools we
service to provide a resource for families that will continue the
efforts to make dental care easily accessible. Last fiscal year the
DDDP provided care to more than 2,300 children on a budget of $180,000.
Mobile units are not a panacea for treatment but they are certainly a
model for providing affordable dental care.
Prevention is an important aspect of reducing costs for dental
treatment. After the death of Deamonte Driver, Governor O'Malley
assembled the Dental Action Committee (DAC). One of the recommendations
was to institute school-based oral health screening programs. The
Maryland Dental Action Coalition, formed from the original DAC,
received $172,000 from the Kaiser Foundation to develop a demonstration
project to determine the feasibility of this type of program in Prince
George's County. The results of the project showed that it is vital to
have a presence in the schools. Of 3,000 children screened, 200 were in
the A category which indicated that they had an immediate need, either
infection or multiple decayed teeth. This indicated 200 more potential
Deamonte Drivers.
It is these types of programs that will address affordable
accessibility. We need a stronger financial commitment to support the
public health infrastructure so that the dental needs of all Americans
can be met.
Thank you again for the opportunity to address this crisis.
Senator Sanders. Thank you very much, Dr. Hughes, and come
back to Bristol. We can use you.
There's a lot to go over. What I propose is that we can do
this kind of informally. I would like to ask each of you
questions, but at the end of the response, if others want to
jump in and comment, that would be great.
Let me tell you a little story about Vermont. About 45
years ago, I moved to a small town in rural Vermont in what we
call the Northeast Kingdom. I saw a kid there, a neighbor of
mine. I'd never seen anything like it in my life. He was maybe
10 years of age, and all of his teeth were rotting in his
mouth. I'd never seen anything like that in my life.
It turned out that he was certainly not unique. We had a
major problem in Vermont then. Over the years, in our State, we
have made some significant progress, and we've done it
primarily through the establishment of Federally Qualified
Health Centers around the State. We now have 43 locations,
eight FQHCs, and in our small State, about 25,000 people are
getting treated, regardless of income, at the community health
centers.
We have established--and this is really a source of great
satisfaction. In low-income areas, way up in the Northeast
Kingdom--Dr. Hughes, you may remember--in the towns of
Richford, in Plainfield, in Burlington, we have state-of-the-
art dental clinics that I think are fairly cost-effective,
because we have a number of dentists and dental technicians who
are practicing there. We have a long way to go.
Now, let me at least start off by saying this. What we have
learned in Vermont is that every time you build--it's like,
``If you build it, they will come.'' It's like the baseball
fields. What we have learned is you build a dental clinic, and
guess what? People come.
Dr. Catalanotto, is that your impression, that the need is
out there, and if we build it, people will come?
Mr. Catalanotto. Absolutely. I look at my own examples in
Florida. At our dental school, which is very large, we have
patients who travel 2 hours away, because they can't find
affordable care in their communities. When I went to Gadsden
County next to the State capital of Tallahassee, on the day we
did a school exam, one in five children reported pain that day
of the exam.
Senator Sanders. One in five children?
Mr. Catalanotto. One in five children on the day of the
exam--this was about 5 years ago--reported pain, one in five,
Senator. A young graduate of ours went to the county health
department and took a job. She's a pediatric dentist who gave
up what she could have made in private practice to work in the
county health department. Overnight, she made it a major
success with large numbers of patients. So, yes, the need is
out there. People will come if provided access to the services
at an affordable cost.
FQHCs are a wonderful partner in doing this. I will tell
you, as an example, all of my dental students at the University
of Florida spend approximately 6 weeks of their clinical year
in an FQHC. Why do the FQHCs love that? It's not the short-term
labor they get. It's that these students finally figured out,
``This is a place I might practice.'' It's no longer the
private practice model. They see the opportunity, sir.
Senator Sanders. Let me ask you a tough question, but it's
just between you and me.
Mr. Catalanotto. Yes, sir.
Senator Sanders. I have the impression today that maybe
there are some great dentists out there who see their job as
treating people in need. But it is also no secret that there
are a lot of dentists who graduate dental school deeply in
debt--and I want to talk about that in a moment--who are making
a pretty penny by treating the upper middle class. If you look
in the Yellow Pages, they've got a beautiful smile, and they do
all the cosmetic dentistry. So we have a lot of dentists
practicing cosmetic dentistry when kids are in pain.
Mr. Catalanotto. Yes.
Senator Sanders. What do we do? What ideas do you have? And
I should tell you we've tried substantially increasing funding
for the National Health Service Corps, which you're familiar
with. What do we do to create the kind of dental workforce that
we need so that we don't have to be embarrassed that there are
huge places in America where people--either there are not
enough dentists, or there are not enough dentists treating low-
and moderate-income people? What's your ideas on that?
Mr. Catalanotto. I can give you three answers. We do need
to improve Medicaid reimbursement. In Florida, we have the
worst Medicaid reimbursement in the United States. The result
is that only 10 percent, approximately, of Florida dentists are
accepting Medicaid.
Senator Sanders. Say that again. I want everybody to hear
that. You have Medicaid, but only 1 in 10 dentists will take
Medicaid patients.
Mr. Catalanotto. That is all, but it's because we have some
of the lowest Medicaid reimbursements in the United States. No.
2, I think there is very clear data that things like National
Health Service Corps scholarships and loan forgiveness programs
are wonderful. There are some States that have them.
We do not have them in Florida. I am happy to say that the
Florida Dental Association has lobbied our State legislature,
but our State legislature is just too cheap to do it.
Third--and this is the longer-term solution--HRSA Title VII
funding provides grants to dental schools. The newest set of
grants is to help change the culture of the dental school and
the culture of dental students. They focus on healthcare
disparities.
I am the principal investigator of one of those grants to
the University of Florida College of Dentistry. And what we are
doing is revamping our curriculum to produce students who are
more culturally competent and sensitive to the needs of the
underserved patients. They have more public health experience.
I've been able to hire a public health dentist to add to my
faculty.
So now second-year dental students go out into a school-
based setting, where they understand. They go into schools of
poverty. They see the picture early in their dental education.
Our goal and our hope is that they will become more sensitive
to this issue after they graduate.
Senator Sanders. And are you finding--and we have the same
issue--we had a hearing here on primary healthcare, getting
doctors, young medical students, involved in primary
healthcare. Are you finding that, given the opportunity, and if
there were decent reimbursement rates, we would be able to
attract more young people to serve lower income folks?
Mr. Catalanotto. Yes. There's no doubt. What I hear from
the FQHCs is,
``Frank, you're sending the students to work for us.
They are seeing the problem. They get a better
appreciation of the needs of these kinds of patients,
and they are going into those settings.''
Yes, sir.
Senator Sanders. Thank you very much.
Senator Franken has joined us, and I wanted Al to be able
to give his opening remarks, if he'd like.
Statement of Senator Franken
Senator Franken. There hasn't been testimony yet?
Senator Sanders. Yes, everybody has testified, first round.
But if you want to jump in and just----
Senator Franken. Yes, I actually want to followup. Thank
you, by the way, Mr. Chairman, for inviting me to attend this
hearing. It's a very important hearing. And I want to pick up
where you were on dental care.
In Minnesota, we became the first in the Nation to create a
license for an advanced practice dental provider called a
dental therapist. This was actually first started in the United
States in Alaska to address the native population there,
because in Alaska, to get a dentist, you would really only get
a dentist once a year, who would fly in for a couple of days.
But now they have dental therapists. Other OECD countries
have dental therapists. I guess the ones who are in Alaska were
trained in New Zealand or something.
Dr. Catalanotto, in your written testimony, you emphasized
the financial impact of the national dental care crisis, and
you were just talking about the limited access to dental care
and how it leads to wasteful spending. The GAO report released
this morning notes that only 62 percent of Americans have
dental coverage, and only about 40 percent of people have a
dental visit in any given year.
You also noted in your testimony that one important way to
expand access to dental care would be for States to consider
dental therapists, like Minnesota. Could you elaborate on that?
And what can we in Congress do to support the expansion of that
program and the expansion of the number of dental therapists?
Mr. Catalanotto. Thank you, Senator. It's a great question.
Just by way of background, I have been to Alaska three times,
looking at the dental therapist model. I have talked
extensively with the folks in Minnesota that have both trained
these dental therapist and then employed these dental
therapists.
Last week, I testified to the New Mexico legislature about
dental therapists, and with me was one of the folks who employs
dental therapists in Minnesota. I have read most of the
literature on this. I am absolutely convinced that this is a
cost-effective, safe, wonderful model to deliver care to people
in need.
The beauty of dental therapists is that they can do the
kinds of simpler procedures that a dentist might do, but that
allows the dentists to work at the top of the scope of their
practice instead of at the bottom of the scope of their
practice. They are inexpensive to educate. They usually come
from the communities they go back to serve--underserved ethnic
minority groups. They are a wonderful solution.
The difficulty comes from the opposition at the State level
and then the national level, which I think was your question.
At the State level, it's restrictive dental practice acts that
forbid these individuals. There are approximately 15 to 20
States that are now this close to legislation to get dental
therapists in their States.
But I would also add that it's not just dental therapists.
These restrictive dental practice acts also prevent dental
hygienists who are excellent at providing some of the primary
services needed--these dental practice acts restrict them from
working at the top of their skill across many States.
At the Federal level, the impediment that currently exists
is that language was inserted into the health service
reauthorization just a couple of years ago that prevents the
first nation folks across this country who want to implement
dental therapists--it prevents them from doing it because
there's language that says they cannot use Federal funds. This
is a travesty. This is an affront to the sovereignty of the
first nations. That is something that you could do at the
Federal level. There's not much you can do at the State level
because of the individuality of dental practice acts.
Senator Franken. I just think this is incredible.
Mr. Nycz, in Wisconsin, you would hire a dental therapist.
Dental therapists, in studies, do the task they're allowed to
do as well as dentists. Am I right?
Mr. Nycz. Yes, that's what the evidence shows. But, again,
because of these State laws, we do not have access. And, of
course, there are not many of them that have been minted.
I'd like to circle back to the chairman's point about, ``If
you build it, they will come.'' The map that we showed shows
that we're taking care of close to 100,000 people who have come
from all over the State. And I would add that maybe 140 to 150
from the good State of Minnesota have come to us for dental
care.
When we see people, when we open up a clinic--and this is
why this is a little nuance--we get people with such horrible
dental disease that young men and women just coming out of
their dental training--many of them are kind of daunted by the
task in front of them. We've had one dentist leave after 6
months, saying they're not prepared for this kind of work.
We had another dentist come and say, ``You know, I'm not
prepared for this.'' She went back and got a year residency,
and now she's going to work for us starting October 1st. So
there's a training aspect.
Dr. Michael McGinnis once wrote about the dirty dozen
reasons why we don't do prevention. One of his points was the
primacy of the rescue. So I would say as it relates to dental
therapists that we have dentists who can't even do the job we
put in from of them when they come right out of training,
because they're not used to that.
But as a health center director, that's what we're faced
with now, that primacy of the rescue. So I need well-trained
dentists, trained even more than they get in their 4-year
schools, to tackle that problem.
But I want to get over the top of that hill, and I want to
have our population find that they can experience the same oral
health level that more affluent people have. And it's at that
time, as our population gets healthier, that we have a
responsibility to the taxpayers as well. We've built group
dentistry practices, with five dentists, 10 dentists, with
hygienists.
And what I see over time is as our population gets
healthier, we need to substitute in other providers who can
handle the more routine things to allow our dentists to
continue to handle and help out on those emergencies and the
more complicated cases. So I see this more in our future, if
these problems that we discussed can be resolved.
Senator Sanders. Let me jump in.
Senator Franken. I wanted to end on it, Mr. Chairman, if I
might, because I have to go back to Judiciary. When we had
testimony on this, we had a dental therapist who worked in a
native village, in her own village. And she said that she was
able to--because she had been from the village, when she would
see kids in the village at the store or somewhere else, she'd
say, ``Brush your teeth every day.''
So when you're talking about this prevention piece, I think
that it's actually key that we have people who are more likely
to go back to where they live. And I think that this is
something I would really like to continue to pursue.
Thank you, Mr. Chairman.
Senator Sanders. Thank you.
Let me pick up where Senator Franken left off. What we're
really talking about is the workforce, in general, whether it's
dental therapists or dentists or hygienists. And let me throw
this out to Dr. Hughes.
What ideas do you have? Dr. Catalanotto made some
suggestions, but is it your experience that we are not
attracting the kind of practitioners that we need to take care
of a population that has a whole lot of needs out there?
Mr. Hughes. Actually, in Maryland, we have seen an increase
in providers participating in Medicaid. We currently have over
1,600 providers. Our access issues deal more with adults not
having coverage. And for those adults that do have Medicaid,
the benefits are so limited that they cannot find a provider.
Senator Sanders. So what happens to them?
Mr. Hughes. They don't get seen.
Senator Sanders. And when they're in pain, what happens to
them?
Mr. Hughes. They go to the emergency room, and then they
are referred to the health department, and that's my other
issue. There's not enough funding for public health
infrastructure. Right now, I could easily have an adult program
in the health department. But when there were budget cuts, one
of the first things that was cut was the money for a dentist
that was seeing the uninsured adult population.
So we don't have funding. We have the capacity, but we
don't have funding. We don't have problems finding providers,
but because we don't have the funding, we can't offer the
services.
Senator Sanders. Moving to what Ms. Stallings talked about.
I think we have all seen pictures, whether it's healthcare or
dental care, of doctors who volunteer their time, pro bono, to
treating folks who don't have access.
Actually, one of my staff members, Erica--I think it was
last year you were in southern Virginia--and, Ms. Stallings,
you mentioned something similar--where it really looked like a
third-world country or maybe a fourth-world country, where
there were people who had terrible health and dental problems
and couldn't find access to a doctor or dentist.
It was hard to believe that this was the United States of
America, where people were spending the entire night, waiting
in line in order to get a tooth extracted or get a basic
checkup to find out whether they had cancer or whatever it may
be. It really did not look like America.
Ms. Stallings, I gather you are familiar with that reality.
Yes?
Ms. Stallings. Oh, yes, definitely.
Senator Sanders. If you are a lower income American. You're
on Medicaid, but you don't have access--Medicaid does not pay
for a dentist. What happens to you? What do those people go
through?
Ms. Stallings. We have an office. One day, I had a client
who was in severe pain. I took her to our main office. We got
her an appointment. I believe it was in a couple of days. And
we were told that they would pay up to $200.
They have very limited funds, and, many times, the only
option is clients waiting months on this waiting list to be
able to be seen in the clinic where people are donating their
time in their free off hours. But the wait list is incredibly
long, and they have to wait for a long time often.
Senator Sanders. So many of your clients are going through
their days in pain.
Ms. Stallings. Well, it's more--when they're in severe
pain, we definitely take action to get any treatment that we
can possibly get. A lot of our clients do lose teeth, do have
extractions, quite a few. If someone is really in pain, we try
to do everything we can with the limited opportunities we have.
Senator Sanders. Let me go back to anybody here.
Dr. Catalanotto, you raised this issue.
We have a crisis. We don't have the workforce to address
the crisis. What role does the ADA, the American Dental
Association, play in all this? And, by the way, we invited the
ADA to be with us today, and they were going to be with us, but
at the last minute they chose not to be here. Are they stepping
up to the plate and addressing the issues that we're talking
about today?
Mr. Catalanotto. In my opinion, in the last couple of
years, there has been a shift in the national picture of the
American Dental Association, in the leadership, and they are
calling more and more attention to the access issue. But one of
my arguments back to them would be, you need to lobby equally
as hard for these access issues as you do for the business
issues that concern you. I'm still not necessarily seeing that
at this particular point.
The State level is totally different. The State
organizations are very independent of the national
organization. So one example would be the American Dental
Association has policies on better licensing procedures. They
support the policies that most dental education does. But at
the State level, that's not particularly happening.
So easier reciprocity between the States is a national
policy of the American Dental Association. It's still impeded
in some States, but it is getting better. I want to be positive
about that.
Senator Sanders. Mr. Nycz, let me ask you a question. You
guys are doing very well. I think we are doing well in Vermont
as well in expanding access. If you had your druthers, have you
done any computations as to what it would take in a State like
Wisconsin--how many more facilities that you would need, how
much more money you would require to provide, in a sense,
universal dental care to the people in need?
Mr. Nycz. It is a big number. Our State asked us could our
State's health centers help them solve this problem, and how
would we help them solve this problem. We said yes, if we
stepped up and we had the resources, we could do that.
When Governor Doyle came to one of our ribbon cuttings, he
said that the approach we're taking is building these group
dental clinics. Many of my private sector dentist colleagues
tell me that you're never going to solve the problem by trying
to get a dentist to establish a practice in this town of 1,000
and this town of 300 and so forth. You need to really somehow
centralize that, usually to the county seat or a place where
people can come.
So that way, we can gain some efficiencies in a group
practice kind of setting. It's easier to recruit and easier to
retain. Governor Doyle said to me when he shook my hand,
``I love this model. I'm wondering about how many of
these we need. Could we have them within 50 miles apart
so nobody goes more than 25 miles, or should it be 40
miles?''
When we simulated this, it does cost a lot of money to do
this. I mean, we were up in the $100 million range. He was a
former attorney general, and he just said, ``Well, these folks,
particularly the folks on Medicaid, have a legal right to these
services, and we've got to find a way to do that.''
We've made great progress, as that map shows. In my written
testimony, I show what, collectively, we've done in the State
of Wisconsin, and Wisconsin has been a wonderful partner to
this day. But the fundamental question you're asking about
cost--it is costly because we've neglected this, because we've
had a population that does undervalue oral health and doesn't
fully understand the importance of oral health to general
health.
And we have the point that you made that around 42 percent,
43 percent visit a dentist every year. It should be more. In
the model that we're trying to do--how do you capture savings?
You can talk about people coming out of school with certain
income targets and having to price things and all that. But the
real savings on this is to raise the oral health profile of the
American people.
The prevention potential in dentistry is gigantic. All of
this stuff can be prevented. So we're engaged in this
generational effort to try to make that difference. And places
that could be helpful--we're grateful in Wisconsin that we have
adult dental in Medicaid.
I've been saying, why don't all States have adult dental?
Why don't we have adult dental in the exchanges? People say we
can't afford it. But then I ask back and say, ``Well, how do we
afford adult dermatology?'' We have to totally change our
thinking and integrate these things.
Senator Sanders. You're absolutely right, and that's why
we're holding hearings like this, just to raise that
consciousness. And you made the point, which is true, that if
you expand access to dental care, it is an expensive
proposition. But if you don't expand access, it is an equally
or perhaps more costly proposition.
Who wants to say a word about people walking into an
emergency room and how much that costs?
Mr. Catalanotto. Senator, we did our own emergency room
report in Florida. In 2010, 115,000 dental visits to the
emergency room at a cost of $88 million. It prompted me to
write an editorial. It was entitled, ``Pay Me Now or Pay Me
Later.'' We're paying for this. We are paying for this today,
every day.
Just the Medicaid cost alone from that $88 million was
approximately $30 million to $35 million. I did a rough
calculation based on Florida Medicaid fees. I could have
purchased 495,000 preventive visits, 495,000 preventive visits,
rather than a wasted visit in a hospital emergency room where
all they get is an antibiotic and pain medication, and they're
told to go see a dentist tomorrow. Well, they can't find a
dentist.
Senator Sanders. Which is why they're there in the first
place.
Mr. Nycz.
Mr. Nycz. We're opening a clinic in Black River Falls, WI,
on Ho-Chunk Nation land in a few weeks. The reason we're there
is because 1,000 folks were leaving that community to go to our
dental clinics in other communities. We are grateful for
Federal funds through the Community Health Center Program,
which you have something to say about, that got us money to
help build and equip that center.
When we asked the public health department for a letter of
support, they sent me a letter that said we have this 28-year-
old--and this gets to the point that it's not just the Medicaid
program, and it's one of the reasons why I think the health
center model is so good. It's the leave-no-one-behind model.
A lot of this evolves into a talk about Medicaid. But as
other panelists have pointed out, there are many people who
don't have Medicaid, or they have Medicaid with no dental
coverage, or they have health insurance with no dental
coverage.
This 28-year-old who worked in the woods--no insurance,
paycheck to paycheck, nothing in the bank--starts getting
sicker and sicker and sicker. His sister starts to worry about
him, and he's just going downhill. She's thinking he's got a
job in the woods, so he must have Lyme disease.
They call the local clinic, and they say, ``I'd like to
make an appointment.'' ``Does he have insurance?'' ``No.'' This
is for physician care. They want a Lyme test. ``Does he have
any money for a down payment?'' ``No, he doesn't.'' ``Well, we
can't give him an appointment.''
He gets worse. She takes him to the public health
department. They go, ``Oh, my goodness. We've got to get you
right to the hospital.'' The hospital folks said he probably
wouldn't have survived another 12 hours--advanced jaw cancer,
three abscesses, sepsis. He's alive today, thankfully. But how
much money had to be spent in the system?
And what haunts me is in that letter of support at the end,
they said, ``Both his sister and I agree that had you had one
of these dental clinics here, this would not have happened.''
Senator Sanders. What we know--and it's true of dental care
and it's true of healthcare as well--is if a Medicaid patient
needs primary care, can't find a primary healthcare provider
and walks into an emergency room, it costs 10 times more than
walking into a community health center. And I suspect the
numbers are similar--but it's not even similar, because, as Dr.
Catalanotto pointed out, the emergency room in a hospital, in
most cases, doesn't really treat the dental problem as well,
but just eases the pain and deals with the infection.
Let me get back to one other issue--and, Dr. Hughes, jump
in if you want to here. The cost of dental school is kind of
off the charts. I remember last year in Rutland, VT, talking to
two young dentists. One of them had graduated from Tufts, I
think--well over $200,000 in debt. What are we going to do
about that?
Ms. Hughes. How do we reduce dental school tuition?
Senator Sanders. If I graduated with $200,000 in debt, I
probably would not be running to a community health center to
make whatever I would make there. I'd probably figure out how
I'm going to make as much money as I possibly can. Is that a
fair statement?
Ms. Hughes. It is. However, if you work at the community
health center, you're likely eligible for loan repayment.
That's what we need to--I think it's important to establish
more of these types of programs. In Prince George's County, we
have a population of over 800,000 people. We only have one
Federally Qualified Health Center and one Safety Net Clinic.
Senator Sanders. That's all you have?
Ms. Hughes. That's all we have. And there is only one
dental shortage designation area in the county. So it is a
daunting task to try to establish an area as a dental health
shortage area, because it requires that you have surveys of all
the dentists in the area and how they practice. That's hard
information to get. They get a survey, and they toss it to the
side. So we have to improve that process.
But I don't know how to answer that question, how we reduce
dental school cost. It's costly to go to school. I mean, in
dental school, we're doing procedures. There's the cost for the
equipment. We're not just sitting in lecture halls. We're
actually doing procedures. So that's why the cost is elevated.
Senator Sanders. I want to get back to Dr. Catalanotto for
a second. You raised an issue that we are familiar with, and
that is the Sarrell situation in what, Alabama?
Mr. Catalanotto. Yes, in Alabama, sir.
Senator Sanders. You see that as a potential model to
provide cost-effective, quality dental care. Yes?
Mr. Catalanotto. Yes, I do.
Senator Sanders. Say a few words about that.
Mr. Catalanotto. They've grown from 1 to 15 clinics in
about 9 years with no grants, only on Medicaid fees. They do it
because, first of all, the culture of caring. I can talk about
that, but that's not the business issue. The business issue is
they run it with a ruthless business model. The CEO was a
Fortune 500 company president at the age of 31. He did this as
a volunteer activity in his community, but now it has turned
into a major not-for-profit business.
Senator Sanders. You're convinced the quality is good?
Mr. Catalanotto. I have been there three times. I have free
rein to get up from my meeting and walk down the hall and walk
into a clinic. Every time I walk in, the parent is in the room.
Just before each visit, they take height, weight, blood
pressure, and temperature and report it back to the parent.
I walk into the room and I see toothbrush--I don't see
procedures being generated. I see prevention being emphasized.
That's the only way they could have reduced care from over $300
to $125 annually.
But what do they do? They use their facilities 50 hours, 60
hours a week. They have mass purchasing power from 15 clinics,
so they're able to get the most cost-effective pricing. They
have a call center.
Senator Sanders. And how do they pay their dentists,
reasonably well?
Mr. Catalanotto. They pay their dentists very well, but not
on production. The dentists are paid a straight salary, whether
they do 15 amalgams or restorations in a day or whether they do
five.
They use this interesting model. The call center staff may
get a bonus for keeping the chairs filled, because they call
their patients. They treat their patients with dignity. There's
a common claim--oh, those Medicaid patients don't keep their
appointments. Sarrell Dental Center has a chair utilization
rate of 99 percent, because they treat their patients with
dignity. They treat them with respect. They make them feel----
Senator Sanders. You're telling me that they are making
money?
Mr. Catalanotto. They are making money. Now, they're a not-
for-profit, so they plow the money back into a new clinic. They
just recently got themselves equipped to do some tele-
dentistry. They do community service. They have great community
outreach. Each clinic has a community person who goes out into
the community, promoting care, promoting getting patients to go
to the clinic and get their dental care. It's a wonderful
model.
Senator Sanders. And their staff feels good about working
there?
Mr. Catalanotto. The staff feels good. So many of their
dental assistants, for example, are college-educated young men
and women because of the economic situation. They care. Sarrell
has now started--there's just one or two--if you want to go to
dental school, if you want to go to dental hygiene school, we
will pay your way if you offer to come back and work here.
Senator Sanders. So they're doing their own National Health
Service Corps.
Mr. Catalanotto. They have their own National Health
Service Corps. And I can tell you I'm on their board, unpaid,
on their board of directors. They want to expand out of State.
They are restricted from doing this because the CEO is an MBA.
Senator Sanders. Mr. Nycz, is there anything in that model
we can learn from?
Mr. Nycz. I think health centers probably could learn from
this model as well. But the task we're faced with, though, is
not just taking care of Medicaid on dental. We have to contend
with adults. We have to contend with people with psychiatric
problems. We have to contend with people with disabilities. So
we have to be a little bit more well-rounded.
For example, we could make our site more efficient if we
didn't include large treatment rooms and wheelchair lifts. We
could make our site more efficient perhaps if we didn't include
space for training. So I think that we can learn from them, but
their model is still fairly focused on a distinct population,
and we have responsibility for everyone.
Senator Sanders. Is Sarrell mostly focused on kids?
Mr. Catalanotto. It is only focused on kids because there
are no adult benefits in the State of Alabama. So they only do
children. He is absolutely right. It is a little different
model. Now, they do some developmentally disabled. They have
recently hired an oral surgeon. They have several pediatric
dentists who can take children to the hospital.
Senator Sanders. But only treating kids.
Mr. Catalanotto. But they only treat children through age
20.
Senator Sanders. Let me just say to Mr. Nycz and to
everybody here that we're going to do our best to focus more
and more attention on this issue--why this hearing is so
important. We're going to do our best to fight for more money
for the community health centers.
We're going to take a look at the issue of dental
therapists. We are going to take a look at models which seem to
be high quality and cost-effective. We want to deal with that.
I think your point about philanthropy is great, that it is not
a solution to a major, major crisis in this country.
Dr. Hughes is here today, and she oversees the Deamonte
Driver Dental Project. Maybe we'll conclude--Dr. Hughes, tell
us--because some people may have forgotten--who Deamonte Driver
is and why the project is named after him.
Ms. Hughes. Deamonte Driver was the 12-year-old that died
in Prince George's County from an abscess. His parent was
unable to access dental care. His Medicaid had lapsed, and she
could not find a dentist to treat the child. He was taken to an
emergency room and given treatment for sinusitis and other
things and released, and then was rushed back to the hospital
and had to have immediate surgery when they found that the
bacteria had spread to his brain.
Deamonte Driver died February 27, 2007. As a result, the
Governor of Maryland said, ``This cannot happen again.'' The
Dental Action Committee was formed, and seven recommendations
were made. Also, from their actions, the Deamonte Driver
Project was initiated. It is a mobile dental unit that goes to
Title I schools throughout the county. We treat all children,
insured and uninsured.
One thing that we really don't talk about is the children
that are uninsurable. We have a large population, in the county
and in the State, of children that are uninsurable, and we see
those children as well.
By definition, a mobile unit in Maryland cannot be a dental
home, and that is not our purpose. We work with families
through case management to ensure that all children are in a
dental home. We are there to treat emergent needs so that we
don't have another Deamonte Driver.
As I talked about earlier, in our process, we are trying to
establish statewide school screenings. Children are required
when they go to school to have immunizations. Why are they not
required to be seen by a dentist?
So in our demonstration project, we saw that there were a
number--it was vital that we were there. There are a number of
children who, had we not seen them, could possibly be Deamonte
Drivers. So we honor the legacy of Deamonte Driver by being in
the schools. We also provide treatment at the school he
attended. The program has been very successful, and it is
welcomed by all the schools that we attend.
Senator Sanders. Dr. Hughes, thank you for the work that
you do on that. I think to remember Deamonte Driver, our job is
to dedicate ourselves to make very, very significant
improvements to our dental care system so we never see another
Deamonte Driver situation again in this country.
I want to thank you all, not only for being here today, but
each in your own individual way for playing such an important
role in addressing this issue. Thank you very much.
With that, let's adjourn the hearing.
[Whereupon, at 11:20 a.m., the hearing was adjourned.]
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