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An Economic Argument for Preventive Care

We’d like to start off this blog post with a quote from the Terry Pratchett novel, “Men at Arms.” The book is a fantasy novel, but the quote underscores an important reality of poverty, that is, it is expensive to be poor.

Image with a quote from Terry Pratchett novel "Men at Arms." Quote reads, "Take boots, for example. He earned thirty-eight dollars a month plus allowances. A really good pair of leather boots cost fifty dollars. But an affordable pair of boots, which were sort of OK for a season or two and then leaked like hell when the cardboard gave out, cost about ten dollars. Those were the kind of boots Vimes always bought, and wore until the soles were so thin that he could tell where he was in Ankh-Morpork on a foggy night by the feel of the cobbles. But the thing was that good boots lasted for years and years. A man who could afford fifty dollars had a pair of boots that'd still be keeping his feet dry in ten years' time, while the poor man who could only afford cheap boots would have spent a hundred dollars on boots in the same time and would still have wet feet."

Pratchett’s fictional “boots theory of socioeconomic unfairness” is a reality for many across North Carolina, and across America, today.

For example, the average washing machine uses 19 gallons of water per load. Accounting for the average cost of municipal water and electricity, running your own washing machine costs a mere 30 cents per load. Nationwide, however, laundromat patrons pay approximately $2.00 per load.

It is over six times more expensive to have clean clothes in America if you’re too poor to buy a washing machine. And that doesn’t even take into account the luxury of an electric clothes dryer.

Saving money is a luxury tied in many ways to wealth. If you have a little extra cash at the end of the month, you can invest your hard-earned dollars in stocks, property, or other means that allow those dollars to grow. You can make decisions to spend money up front that allow you to save down the road. For example, you can decide to spend an extra few thousand dollars on a newer, more efficient vehicle, saving money on gas and repairs in the long-run.

If you have mouths to feed and rent to pay, and you’re living paycheck-to-paycheck, you generally will end up spending more on basic necessities than you would if you had more economic flexibility.

Quote from a Sarah Smarsh essay, "Poor Teeth." Quote reads, "Poor teeth, I knew, beget not just shame but more poorness: people with bad teeth have a harder time getting jobs and other opportunities. People without jobs are poor. Poor people can’t access dentistry – and so goes the cycle.”

If you are poor in North Carolina, you are more likely to lack access to basic preventive care and oral health education as a child. As a result, you are more likely to experience tooth decay, both as a child and later as an adult.

Insurance aside, the average cost of one filling runs between $200 and $600.

For a root canal, average costs range from $700 for a front tooth up to $1,800 for a molar. Add the necessary crown following a root canal and you’re looking at an additional $300 – $3,000, depending on the crown’s material.

There are many options for low-cost dental care using sliding scales based on income, but at the end of the day, even one tooth with serious decay is much more expensive than an annual checkup and cleaning (especially with insurance, which generally covers the entire cost of routine preventive care).

Outside of the dental office, oral health takes an additional economic toll. How do you think a missing front tooth would impact your job prospects? Your confidence? Your ability to eat healthy foods?

North Carolinians visit emergency departments for oral care at twice the national rate. This particular statistic may be the most shocking, as the majority of hospitals are entirely unequipped to handle oral disease.

If you go to a hospital once you can’t handle the pain of your toothache any longer, you are likely to be prescribed an antibiotic and an opioid. Opioids are only a temporary fix for pain, and they bring with them a host of other potential problems. Antibiotics are not a solution for oral disease, either, but a temporary solution to potentially address the acute need. The pain and swelling may go away temporarily, but the root cause will still be in your mouth, potentially landing you back in the emergency department in a few months, with a new hospital bill.

In the same way that individuals with economic flexibility can spend dollars up front to reduce costs down the road, systems can operate in a similar fashion. In oral health, and in health care in general, dollars invested in preventive care—spent up front and before issues emerge—can not only lead to the best health outcomes, but they can also create more economically sustainable systems.

We need to structurally change the oral health care system in North Carolina, ensuring that every single child and adult has access to quality preventive care and oral health education. Beyond being the right thing to do, it is a fiscally responsible move that will save both individuals and our state government money in the long run.

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.

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Proposed Legislation Would Formalize Teledentistry and Allow Hygienists to Administer Local Dental Anesthesia

On February 24, 2021, Senator Jim Perry and Representative Donny Lambeth filed legislation in the North Carolina House and Senate to formalize the practice of teledentistry and allow dental hygienists to administer local anesthesia.

For the purpose of this blog post, we will refer to the legislation as SB 146. The Senate and House bills were identical when filed, a common practice in the legislature.

SB 146 represents two important steps toward a future where all North Carolinians can access quality, affordable oral health care. Here’s what you need to know about the legislation and its path forward.

Cutout of proposed Senate Bill 146

What’s in SB 146?

If passed into law, SB 146 would do two important things. First, it would formally define teledentistry in North Carolina’s Dental Practice Act, setting forth patient protections and allowing for patient evaluations to be conducted via remote modalities.

Prior to the COVID-19 pandemic, the NC Department of Health Benefits (Medicaid) reimbursed for synchronous teledental services, but not for asynchronous. However, as a part of their COVID-19 relief provisions, Medicaid added asynchronous reimbursement as a way for providers to further connect with the patients they serve. We believe this legislation will help signal to payers, both public and private alike, that teldentistry’s role in the future of oral health care delivery is both safe and effective.

Teledentistry has been, and will continue to be, an important tool in helping providers reach patients who wouldn’t traditionally have access to care. It can connect dental care teams in non-traditional dental settings, such as schools and long-term care facilities. Teledentistry can also expand service options in rural North Carolina — where providers are more scarce. All in all, teledentistry makes it more feasible for providers to improve access and equity in care.

Second, SB 146 would allow properly trained dental hygienists to administer local anesthesia. This clinical responsibility — which has already been authorized and delegated to hygienists in 44 other states and Washington D.C. — can help practices increase efficiency, reduce costs, and care for more patients.

North Carolina has historically been one of the more restrictive states in terms of the clinical procedures dental hygienists are permitted to perform. Fortunately, recent regulatory reforms such as the change to Rule 21 NCAC 16W .0104 have begun the process of updating the delegation of duties in the dental office. SB 146 represents an important next step, and we commend and thank Senator Perry, Representative Lambeth, and the stakeholders including the North Carolina Dental Society who worked to make this happen.

Where is the bill in its path toward becoming law?

As of March 17, both bills (SB 146 and corresponding HB 144) have moved through one committee in their respective chambers.

On the House side, HB 144 was referred to the committees on Health, Insurance, and Rules. This means that the Health Committee, Insurance Committee, and Rules Committee all must vote on the bill before it will be voted on by the entire House of Representatives.

On March 9, 2021, the Health Committee approved of the legislation with minor technical changes, passing it on to the Insurance Committee.

On the Senate side, SB 146 was referred to the committees on Health Care, Commerce and Insurance, and Rules. This means that the Health Care Committee, Commerce and Insurance, and Rules Committee all must vote on the bill before it will be voted on by the entire Senate.

As of March 17, 2021, the Health Care Committee approved of the legislation, inclusive of the minor technical changes that were first introduced to HB 144, and it now will move onto the Committee of Commerce and Insurance.

Whichever version of the legislation reaches a vote of its respective full chamber first will cross over for a vote in the alternate chamber. In other words, if the House bill is approved by the Insurance and Rules committees, and the full House of Representatives votes in favor of the bill, then the Senate will need to vote in favor, as well, or vice versa.

If both chambers vote “yes” on either version of the bill, then the legislation will be sent to Governor Cooper to be signed into law.

The steps between the proposal of legislation and the legislation becoming law can be complicated, but we will break down the process every step of the way. Stay up to date on the movement of SB 146 and HB 144 by signing up for NCOHC News today!

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The New HPI Report – NCOHC’s Perspective

What does “access” really mean?

The American Dental Association Health Policy Institute (HPI) released a report earlier this year analyzing access for those with Medicaid/CHIP insurance across North Carolina. After taking a deep dive into the contents of the report, those of us at NCOHC kept reflecting on what access truly means, how our definitions of access can impact data collected, and how that data can in turn influence policy.

We recently published a summary of the main points in the HPI Report, which you can find here. As a brief recap, the report found that:

  1. Supply of “meaningful” providers —meaning providers who meet a benchmark of $10,000 in Medicaid claims each year — varies geographically for both children and adults.
  2. While overall utilization among children is above the national average — with 58.9 North Carolinian children seeing a dentist within the past year versus 51.7 percent nationwide — there are also areas where utilization falls below 25 percent.
  3. Dental care utilization among Medicaid-insured adults is low, at 18.7 percent statewide, versus 23.2 percent nationwide.
  4. Medicaid-insured individuals are less likely to secure appointments compared to their privately insured counterparts.

So, What’s Next?

The bottom line is that, as long as disparities exist in our oral health system, structural change will continue to be needed in order to bridge divides and increase equity in care.

At NCOHC, we believe that a future where those with Medicaid insurance or who lack coverage altogether can access care just as easily as their privately insured counterparts is not only achievable but absolutely necessary.

We believe that where you live, how much you earn, your race, ethnicity, or any of the other social determinants of health that have been shown to impact access to oral health care shouldn’t determine whether you can achieve optimal oral health. And we believe there are simple steps that North Carolina can take to structurally change inequities that exist along these lines.

Policy change will be an important piece of the puzzle as we work to change how care is provided and received. NCOHC released its first policy brief in 2020 outlining a variety of changes that are evidence-based and shown to successfully and equitably improve access to care.

At NCOHC, we are particularly interested in the potential that community-based models of care offer. One step in connecting community-based dental sites is through the promotion of remote care technology. This is especially critical to increasing access in rural North Carolina, and when coupled with enhancement strategies to more effectively utilize the dental hygiene workforce, leads to greater and more equitable access to critical oral health care services for all.

Keep your eyes on House Bill 144 and corresponding Senate Bill 146, which were recently filed in the North Carolina General Assembly. Along with defining teledentistry and authorizing patient evaluations to be conducted through remote technologies, the bill would allow dental hygienists to administer local anesthesia.

Stay up to date on the status of House Bill 144 and Senate Bill 146, as well as hear about additional oral health content by signing up for NCOHC News today!

Equity in Data

There is another conversation to be had — one about equity in data. It is easy to see data as a race-neutral, impartial juror in the realm of scientific discovery and analysis. But that’s not always the case.

Recently, data collection and equity have become prominent in the COVID-19 conversation. As states distribute vaccines, data collection is proving to be a critical step in equitable distribution planning. In fact, North Carolina is one of the more equitable states in vaccine distribution, thanks in large part to an early focus on data collection.

In future research pertaining to oral health care access, NCOHC hopes to see a greater stakeholder focus on the social determinants of health and their impact on health outcomes. For example, access to care was measured in the HPI report by a 15-minute travel time between patient and provider, but does 15 minutes mean access if a patient lacks transportation, childcare, or time off from work?

It is important to note that NC Medicaid offers transportation to appointments, an important step toward navigating transportation barriers.

Access can mean different things to different communities, and as oral health professionals seek to understand the landscape of access, and work to remove barriers to care, it will continue to be important to improve how we collect and analyze data.

For anyone interested in learning more, this Urban Institute webinar is a good resource on centering racial equity in data use. The Urban Institute also has a well-developed white paper titled, “Principles for Advancing Equitable Data Practice.”

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Envisioning Preventive Bundled Payments

Hannah Cheung is a second-year graduate student pursuing her master’s degree in Public Health, and master’s degree in Dental Hygiene Education at the University of North Carolina. Her focus is to combine her knowledge of dental hygiene and public health to promote the importance of oral health care and education in the state.

Despite significant investments to increase access to oral health care in the United States, the prevalence of decay in children during the past few decades is still concerning. The traditional fee-for-service model (FFS) has been the dominant dental reimbursement system for years. Since FFS pays providers for the amount of service provided, the model rewards for high-cost, complex, and time-consuming procedures. As a result, prevention and maintenance of oral health outcomes are not well prioritized or incentivized in dentistry.

It’s time to truly consider alternative payment models that align oral health outcomes with financial incentives.

What are preventive bundled payments?

Bundled payment models are a type of value-based care, a patient-centered approach that focuses on financial incentives for preventive care and improving health outcomes. In a preventive bundled payment model, specific preventive services are “bundled” together to be completed in one episode of care.

How can we implement this in a school-based setting?

In a school-based setting, the preventive bundle would consist of an oral exam, cleaning, fluoride varnish, and sealants. There is much research indicating that sealants are 80% effective in preventing tooth decay. Therefore, sealants will receive a “bump” in reimbursement to properly incentivize providers to complete them in the same bundle. To properly utilize the oral health workforce, dental hygienists will visit schools to capture data for the exam, perform the cleaning, apply fluoride, and place sealants. The data will then be sent to dentists, who will perform the dental exam asynchronously. (What is asynchronous care? Learn more here.) If the dentist finds that further treatment is needed, the patient will be contacted and scheduled for a follow-up appointment to receive the necessary care.

What are the benefits?

There are many benefits of bundled payment models. By rewarding the value of care provided instead of the volume of care given, we are putting the patient at the center of care and prioritizing measures that prevent expensive oral disease before it happens. Research has linked bundled payments to improved health outcomes, minimization of downstream costs of care, and time savings for both patients and providers.

Infographic titled "Volume vs. Value" about bundled payment care models

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!

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A Quick Summary of the New ADA HPI Report on Oral Health Access for Medicaid-Insured Patients

Haven’t had time to read the new HPI Report analyzing access for children and adults with Medicaid/CHIP insurance in North Carolina yet? We’ve got you covered.

Earlier this year, the American Dental Association Health Policy Institute, in collaboration with the North Carolina Dental Society and the North Carolina Department of Health and Human Services, published an analysis of access to oral health care for North Carolinians with Medicaid/CHIP Insurance.

To provide context as we continue to break down the report and discuss next steps to create a more equitable, accessible North Carolina, we put together a brief summary of the report’s highlights.

Key findings from HPI’s analysis include:

  1. Supply of “meaningful” providers—meaning providers who meet a benchmark of $10,000 in Medicaid claims each year—varies geographically for both children and adults.
  2. While overall utilization among children is above the national average, with 58.9 North Carolinian children seeing a dentist within the past year versus 51.7 percent nationwide, there are also areas where utilization falls below 25 percent.
  3. Dental care utilization among Medicaid-insured adults is low, at 18.7 percent statewide, versus 23.2 percent nationwide.
  4. Medicaid-insured individuals are less likely to secure appointments compared to their privately insured counterparts.

Dr. Mark Casey, dental officer for the North Carolina Division of Health Benefits (NC Medicaid), penned an introduction to the report, tracing a history of innovation from the groundbreaking 1998 North Carolina Institute of Medicine “Task Force on Dental Access,” to a landmark lawsuit requiring NC Medicaid to raise reimbursement rates, and to the creation of “Into the Mouths of Babes”.

“NC Medicaid and its partner, the North Carolina Dental Society, agree that there is much work left to do to fulfill the promise of better oral health for the disadvantaged in our state,” wrote Casey. “However, it is also important to take note of the progress that has been made over the last 20 years from a time when the vast majority of publicly insured children were not receiving an annual dental visit.”

Casey also recently sat down with NCOHC for an interview about the HPI Report and his takeaways, which you can read here.

The HPI Report authors found that 90 percent of Medicaid-insured children live within 15 minutes of a participating dentist. It is important to note that this figure includes the entire pool of participating providers, not just “meaningful providers.”

When you filter for meaningful providers and break the data down geographically, access gaps begin to emerge.


Map of meaningful provider density compared to Medicaid patients in NC

The HPI Report authors outlined two important factors that contribute to North Carolina’s access gaps: the supply of dentists and the demand for dental services.

In the images above, red areas signify more than 2,000 Medicaid/CHIP-insured patients per meaningful provider. The grey areas, which are especially significant in the western and eastern parts of the state, lack a Medicaid office altogether.


Map outlining supply versus demand for Medicaid services in NC

When comparing supply versus demand, a clearer picture emerges, highlighting Northeastern and Western North Carolina as the two regions with the most pressing access disparities.

Looking forward, there are both good and bad signs for North Carolina…and there is a lot of work that can be done to increase access and equity in care.

On average, Medicaid/CHIP-insured patients have a more difficult time securing appointments compared to their privately insured counterparts. What work can be done to end this disparity?

HPI projected a net increase in practicing dentists in North Carolina in the coming years. Can North Carolina provide adequate incentives to encourage new providers to practice in underserved, rural areas?

Be sure to stay tuned for NCOHC’s perspective on the findings in the HPI Report and the collaborative’s suggestions for next steps to increase access and equity in oral health care! We will publish a full analysis soon. In the meantime, here are a few of our immediate takeaways:

  1. In rural NC, innovative approaches to practicing dentistry — such as teledentistry and school-based care— can significantly improve access to those with Medicaid/CHIP insurance.
  2. We need North Carolina stakeholders to work together and find innovative ways to incentivize newly graduated dentists to serve patients in underserved regions.
  3. We are excited to work with stakeholders, both in private practice and public health, to find ways to increase the number of dentists serving Medicaid/CHIP patients, and similarly, to increase the number of patients participating dentists serve each year.

What changes do you think will help North Carolinians? Get involved by heading over to NC4Change and signing up for a focus group 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!