The New HPI Report: A conversation with NC Medicaid Dental Officer Dr. Mark Casey

At the beginning of the new year, the American Dental Association Health Policy Institute released a new statewide report on oral health access for North Carolinians with Medicaid dental coverage.

As those of us at NCOHC read through the report, we saw both encouraging signs and cause for concern. For more perspective, we spoke to Dr. Mark Casey, dental officer for the North Carolina Division of Health Benefits (NC Medicaid).

Our conversation with Casey covered two important points. First, how are we measuring access to providers, and how could that measurement be improved? Second, what strategies can be implemented to increase use of benefits to ensure that more North Carolinians are accessing oral health care?

What is a “meaningful provider,” and how can the metric be improved to better measure access?

From the report: Out of 2,295 pediatric providers who accept Medicaid/CHIP insurance, HPI found 1,522 to be meaningful providers. For adults, 988 of the 2,160 Medicaid/CHIP providers were found to be meaningful providers.

The HPI report measured Medicaid participation with a “meaningful provider” benchmark of $10,000. This means that a provider who accepts Medicaid/CHIP insurance is considered a meaningful provider if they file $10,000 or more in claims with NC Medicaid each year.

This kind of benchmark offers important insight, filtering out providers who may only see a handful of cases each year, and revealing a map that better shows where access points truly exist.

But while $10,000 has been a standard benchmark, Casey thinks that the number should be higher, given changes over time in reimbursement rates and baseline cost of care.

“It really doesn’t take much in the way of claims activity to hit the $10k threshold these days,” said Casey. “The fact that this level of participation has not changed for 20 years ignores the inflationary pressures on costs to provide treatment and increases in reimbursement rates for providers.”

Casey said that he would like the reimbursement threshold to be $25,000 or $50,000.

He also mentioned that some organizations opt instead to measure meaningful providers by the number of Medicaid or CHIP patients treated in a year, a benchmark that would not be subject to change due to inflation or changes in reimbursement rates.

How do we increase the percentage of Medicaid-enrolled children and adults who use their benefits and see a dentist each year?

From the report: HPI found that 90 percent of Medicaid/CHIP-insured patients live within 15 minutes of a participating dentist, but only one-fifth of Medicaid-enrolled children and one-fifth of Medicaid-enrolled adults live in areas with an enrollee-to-meaningful provider ratio that is less 500-to-1.

To increase participation among this population, Casey discussed a two-fold approach.

First, he said that he believes more coordinated, innovative education initiatives between interested stakeholders would help encourage parents to take their children in for routine care.

Second, Casey said that a closer look at the population of participating dentists is important as well.

“I think we have a large number of providers who are on the low end of the Medicaid spectrum of participation,” said Casey. “I really do think that if the professional membership groups encouraged providers to participate—take 5-10 families as new patients for the year—we would see a spike in participation.”

According to Casey, both increasing the number of patients that enrolled providers see, and encouraging non-participating providers to begin seeing Medicaid patients, is critical to increasing access to care.

An innovative addition: hospital dental clinics

Casey discussed increasing the number of hospital dental clinics in North Carolina as an addition to the oral health care landscape that could increase access to important services, especially for some of the most underserved populations.

“With hospital dental clinics, my main goal is to provide a safe place for dental treatment for patients who have co-morbidities,” said Casey. “My thinking is not just diversion of dental emergencies from the ER, but also as our population ages, there are going to be a lot more elderly folks with chronic medical conditions that put them at risk for problems during a dental office visit.”

Casey also mentioned that hospital dental clinics could offer better options for dental patients with intellectual and developmental disabilities, a population that remains underserved in much of North Carolina.

Stay tuned for more analysis of the HPI report and NCOHC’s thoughts on the approaches needed to create a North Carolina where everyone has access to quality, affordable oral health care.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!


Creating a vaccine to saves lives: How HPV vaccines are revolutionizing cervical cancer prevention

In the early 1990s, cervical cancer was the most common cancer among women. Today, it has dropped to fourth place, thanks in large part to successful screening programs and human papillomavirus (HPV) vaccination.

Dr. Jennifer S. Smith, a vaccine epidemiologist and professor in the Department of Epidemiology at the UNC Gillings School of Global Public Health, has worked on cervical cancer prevention for most of her career. She said that scientific advancement, especially in the realm of HPV vaccine development, has played a critical role in preventing the cancer and saving lives.

“When I first started working on cervical cancer, we didn’t have the vaccines yet,” said Smith. “At that time, we weren’t even 100 percent clear that HPV caused cervical cancer, but scientific colleagues were able to determine it through a number of really important studies around the world.”

Fast forward to 2020, HPV vaccines are now available and have the potential to prevent nearly 90 percent of cervical cancer.

HPV vaccination is recommended for universal use between 11 and 14 years of age in the United States.

NCOHC has focused on the HPV vaccine as an important preventive measure against oropharyngeal and head and neck cancer, but the vaccine can prevent a host of other cancers, too. For more on HPV and oropharyngeal or head and neck cancer, you can download NCOHC’s fact sheets for patients and providers here, and read more about dentist-administered vaccines here.

So, how do you go from a possible relationship between a cancer and a virus to a lifesaving vaccine?

According to Smith, epidemiological research, the study of causes and distribution of diseases, is a critical part of the process. With HPV, one of the first steps toward an effective vaccine was the discovery of its relationship to cervical cancer.

HPV is the most common sexually transmitted infection (STI), with about 43 million infections in 2018, according to the CDC. HPV infection is very common and is often harmless. In many cases, people who contracted HPV don’t even know they had it.

Image of Dr. Jennifer S. Smith, an epidemiologist at the UNC Gillings School of Global Public Health

“As an epidemiologist I want to understand disease natural history,” said Smith. “All of that plays right into understanding, for example in the case of HPV, the specific individual infection types that cause invasive cancers. All of that epidemiology data goes right into the development of the vaccines.”

After decades of research, strong links have been discovered between HPV and cervical cancer, anal cancer, cancer of the penis, vagina, and vulva, and oral cancers. In total, 21,100 women and 14,700 men will be diagnosed each year with an HPV-related cancer, according to the CDC.

“The current generation of HPV vaccines are estimated to prevent about 90 percent of invasive cervical cancer cases, so it is a really good example of how understanding the virus and how it causes cancer informs vaccine development in order to prevent death,” said Smith. “That is ultimately what we’re after—we vaccinate to save lives.”

The work doesn’t stop with a successful vaccine

Vaccine uptake—actually getting people to take the vaccine once it has been developed, tested, and approved for use—is the next step. Smith has been involved on this front as well, working to figure out how to get accurate information to parents as they consider whether or not to vaccinate their children.

Smith helped start Cervical Cancer Free America, a network of coalitions with the goal of eliminating cervical cancer through vaccination, screening, and education.

“We started Cervical Cancer Free America working in a number of states to try and build coalitions to address cervical cancer prevention,” said Smith. “I think it is absolutely critical to think on a state-by-state level. It is critical to have local tailoring of messaging and local commitment.”

Smith referred to Dr. Noel Brewer, another UNC Gillings School of Global Public Health professor who studies health behaviors around cancer prevention and vaccination. Brewer’s work includes teaching health care providers how to communicate more effectively with patients about vaccines.

“I think the very clear message is that the biggest persuader, or the biggest factor that might influence a parent’s decision to vaccinate their child, is their trusted clinical provider,” said Smith.

Providers often giving HPV vaccines are pediatricians, who may not be as familiar with invasive cancer outcomes as gynecologic oncologists, for example, who are the health care professionals taking care of cervical cancer patients.

Understanding the HPV vaccine in terms of a disease endpoint, such as cervical cancer, is vital in accurately communicating with patients and their parents.

“The question I have is, we know that HPV causes cervical cancer. We know it causes other cancers. It causes anal cancer and oral cancer in both men and women. It also causes penile cancer in men and vaginal and vulvar cancer in women. And we don’t have many good ways of screening for a number of these cancers,” said Smith. “Why wouldn’t you vaccinate your child if you knew you could prevent a virus that can cause all of these cancers?”

For parents considering vaccinating their children, the best time to vaccinate for HPV is between 11 and 14 years old. For more information on the HPV vaccine, visit Cervical Cancer Free America.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!


Breaking Down the Oral-COVID Connection So Far

cracked tooth and COVID virus graphic

If it isn’t clear by now, COVID-19 is not just another flu.

In November, the New York Times published an article with the alarming headline, “Their Teeth Fell Out. Was It Another COVID-19 Consequence?” The article followed the story of one COVID-19 “long-hauler,” the term given to those who experience a wide range of symptoms long after they initially contracted the virus, ranging in from common symptoms like coughing to more unexpected manifestations like early symptoms of Parkinson’s Disease.

Before we go further, we’re going to stop right here and clarify that most of the information in this post is anecdotal. So, it wouldn’t be correct to say with certainty that “COVID-19 causes Parkinson’s Disease.” Doctors and patients are continuously discovering new symptoms and manifestations of COVID-19, and it will take some time for researchers to study the disease and find out why certain people’s bodies react the way they do.

But it’s worth talking about the more unexpected side effects experienced by long-haulers, if for no other reason than to reaffirm just how important it is to take steps to ensure that you are protecting yourself and those you love from the virus.

Are there direct connections between COVID-19 and oral issues?

The person interviewed by the New York Times — who noticed a loose tooth while chewing a breath mint only to have the tooth fall out the next day without pain or blood — had a history of smoking. When she visited her dentist, he discovered that she had bone loss in her jaw from when she used to smoke, which likely contributed to the loss of her tooth. But why hadn’t her tooth fallen out until it did? Or, what caused it to fall out when it did? Another long-hauler mentioned in the article, a 12-year-old with healthy teeth, also suffered tooth loss. (At 12, he had no history of smoking.)

One possible explanation is that COVID-19 in some way, shape, or form, could exacerbate pre-existing oral conditions. If that is the case, there is still significant cause for concern, as nearly half of the adult population in the United States has some form of periodontal disease.

Researchers are focusing more and more on the impacts that COVID-19 has on blood vessels, which also could help explain oral manifestations and other seemingly unrelated symptoms. We know that blood vessels are the conduit for many diseases with oral manifestations like heart disease and diabetes. Tie in COVID-19 symptoms like blood clots, bleeding of brain vessels, and rashes, and the possibility of oral implications makes a bit more sense.

A clearer picture: indirect consequences of COVID-19

Beyond the possibility of scary side effects of COVID-19, there are a couple indirect oral manifestations of simply existing during a pandemic that are worth talking about.

For example, take this New York Times interview with a Manhattan dentist who has seen a massive increase in cracked teeth among his patients since the onset of the pandemic. As more people are working from home, crouching over laptops on couches and kitchen chairs, or working in stressful situations, clenching jaws and cracking teeth are becoming important concerns.

Similarly, early in the pandemic, most dental offices cancelled all routine care, only offering emergency services. While this move was necessary to ensure patient and provider safety as proper protocols were created and put in place, it did cut off an important aspect of preventive care for many. Even as dental offices for the most part have reopened, without doubt there will be some portion of the population too nervous to schedule their next cleaning or dental exam.

The bottom line

At the end of the day, there are more unknowns than knowns when it comes to the oral consequences of the COVID-19 pandemic. There are more unknowns than knowns when it comes to the consequences in general, from our heads to our toes. At NCOHC, we are certain about three things:

  • First, schedule your next regular dentist appointment if you can, and if you are uncomfortable, have a conversation with your dentist about their safety protocols.
  • Second, brush up on your oral health education, and make sure you and your family are taking the steps you can at home to keep your mouths healthy and happy.
  • Third, there are people who can’t afford to see a dentist, and there are people who have not received proper oral health education. Advocacy for policy change is one of the most impactful things we can do to structurally change the oral health landscape, increasing access and equity in care.

If you want to get involved and build a better oral health ecosystem in North Carolina, join us today!

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!


Why Teledentistry?

The COVID-19 pandemic has made it very clear that telemedicine is a necessary tool in most healthcare fields. Teledentistry in particular has been an effective means of connecting patients with oral health care providers while prioritizing patient and provider safety. However, beyond the scope of health care during a pandemic, teledentistry has invaluable benefits that will continue to improve equity and access in care, even post-COVID-19.

That’s why improving the legal framework around teledentistry is one of NCOHC’s top priorities in 2021.

Graphic displaying the differences between synchronous and asynchronous teledentistry

Why does policy change need to happen for teledentistry to be used?

Any dental provider anywhere in North Carolina can use teledentistry to some extent today. However, teledentistry is not well-defined in North Carolina’s Dental Practice Act—which makes sense, as remote care technologies are fairly recent innovations.

Fortunately, the North Carolina Division of Health Benefits (NC Medicaid) did enact temporary provisions allowing providers to bill for teledental services while the COVID-19 pandemic continues to require heightened safety precautions. Private payers in NC have also embraced teledentistry by incentivizing its use during COVID-19. NCOHC believes that these provisions should be made permanent.

Why do we need teledentistry post-COVID-19?

Teledentistry is an important means by which to increase access and equity in oral health care. There are counties in North Carolina without any practicing dentists. Expanding the use of teledentistry and permanently adopting appropriate payment models would allow many North Carolinians, especially in rural areas, to access care they might otherwise not receive.

There are several social determinants of health that affect a person’s ability to access reliable health care. Some of the biggest include lack of access to reliable transportation, the inability to take time off work and, for parents, difficulty finding someone to take care of their children while they are away.

Teledentistry can be used to help overcome some of these barriers. Obviously, dentists cannot fill a cavity remotely and a hygienist won’t be cleaning teeth remotely. Nevertheless, streamlining the process can significantly ease the burden on patients short on time, transportation, and more.

Take for example a patient who goes into the office for a routine exam and cleaning appointment and is found to have a cavity. Often, the filling is scheduled as a follow-up appointment. If basic screening is conducted remotely, the required two trips to the office, two periods of time off work, two babysitters, and so forth, could possibly be cut in half.

On the flip side, follow-up appointments to check in with patients who recently had work done can be conducted remotely, again reducing the burden on those seeking care.

For more information on teledentistry, visit our accompanying blog post, “Envisioning Teledentistry in North Carolina.”

So, what’s next?

Permanently adopting teledentistry payment models would reduce obstacles for dentists who want to offer remote care options and provide greater efficiency in care delivery.

Providers — especially those in safety-net clinics with thin profit margins — already frequently use teledentistry, often without reimbursement. Safety-net providers will continue to use teledentistry to provide patients with essential care, and it is important that payment systems support this innovation in care delivery through equitable payment schedules.

Stay tuned as NCOHC works during the 2021 legislative session to ensure teledentistry legislation is passed. Head over to NC4Change and help us take steps forward for positive change today.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!