Author: NC Oral Health Collaborative

Oral health providers: Make sure to scroll to the bottom of this post to learn more about a school-based oral health grant opportunity from The Duke Endowment, the Blue Cross and Blue Shield of North Carolina Foundation, and the Blue Cross and Blue Shield of South Carolina Foundation

The COVID-19 pandemic has offered many lessons for public health, one of the greatest being the importance of “meeting people where they are.” Whether it be serving patients remotely via teledentistry or enabling dentists to deliver COVID-19 vaccinations, the oral health care community has shown resilience and innovation in expanding access to care during the pandemic.

Yet there are many more opportunities to increase access and equity in oral health care, both during and post-pandemic. One of these opportunities is expanding school-based dental programs.

In this post, we’ll take a look at school-based dental programs — what they are, why they’re needed, and how they can transform overall health in North Carolina by increasing access to oral health care for some of our state’s most vulnerable populations.

What Are School-Based Dental Programs?

School-based dental programs provide a range of oral health care services directly to students. While the extent of services offered varies, every school-based dental program brings care into the community, providing access to oral health care that many vulnerable populations may otherwise be denied.

Some school-based dental programs utilize fixed equipment in schools, while others rely on mobile clinics parked on school property. Services provided may include, but are not necessarily limited to:

• Oral screenings and risk assessments
• Fluoride varnish applications
• Dental sealant applications
• Oral prophylaxes
• Radiographs
• Oral hygiene instruction
• Nutrition and/or tobacco counseling

Above all, the configuration of school-based dental programs is flexible, and there are impactful ways to meet communities’ needs across all types of clinical models (more on this a little later).

In particular, school-based dental programs are uniquely positioned to address the social determinants of health, many of which present significant barriers to oral health care for school-aged children. The success of these programs in driving positive oral health outcomes is also well-documented, as we will explore further in this post.

“School-based health programs can level the playing field for children otherwise unable to access oral health care services,” says Dr. Zachary Brian, director of the North Carolina Oral Health Care Collaborative (NCOHC), a program of the Foundation for Health Leadership and Innovation (FHLI). “These programs offer an approach that can significantly increase access and equity for children across our state.”

The Need for School-Based Dental Programs

The need for improving access to oral health care for children in the United States is starkly evident, as is the opportunity for school-based dental programs to address disparities and barriers faced by at-risk populations.

Dental caries (cavities) is the most common chronic disease among U.S. children, according to the U.S. Department of Health and Human Services. According to the Centers for Disease Control and Prevention (CDC), roughly 52 percent of U.S. children have had a cavity in their baby teeth by the time they are eight years old.

In North Carolina, almost 50 percent of schoolchildren have tooth decay, according to the NC Department of Health and Human Services, Oral Health Section.

Disparities in oral health status between socioeconomic groups are also widespread. The CDC reports that low-income children are twice as likely to have cavities as higher-income children. In North Carolina, the picture is just as bleak. According to an analysis by NC Child, “children from poor, rural counties [in North Carolina] tend to have the highest rates of decay.”

“We have a high percentage of schools with students who get free and reduced lunches. We have some schools where 100 percent of our students receive that free lunch because of how many of them qualify under the federal poverty level,” said Dr. Elly Steel, dental clinical director at the Cabarrus Health Alliance, which has operated a school-based program since 1999. “With these children who aren’t getting access to care in other places, bringing the care to them at their schools is really helpful.”

Racial and ethnic disparities are extreme, as well. A study of more than 70,000 North Carolina kindergarteners found that “the prevalence of dental caries was 30.4% for White, 39.0% for Black, and 51.7% for Hispanic students.”

The Importance of Oral Health for Children

With an ever-increasing amount of evidence establishing a connection between oral health, overall health and wellbeing, the case for expanding access to oral health care for children is clear.

Oral health plays an important role, not only in children’s overall systemic health, but also in their well-being and social development. The CDC reports that, “on average, 34 million school hours are lost each year because of unplanned (emergency) dental care.”

The data in North Carolina is similarly damning, with an analysis finding that “children with poor oral health status were nearly 3 times more likely … than were their counterparts to miss school as a result of dental pain.” The study concluded that children with poor oral health status were also more likely to perform more poorly in school.

Oral health is also integrally connected with a child’s self-esteem and behavioral health: one recent study found that “various dental disorders … cause a profound impact on aesthetics and psychosocial behavior of adolescents, thus affecting their self-esteem.”

Social Determinants of Health

The social determinants of health are significant factors driving disparities in access and outcomes for North Carolina’s school-age children. Parents and caregivers often lack access to reliable transportation to take children to and from dental appointments. And even when transportation is available, however, it may be impossible to get time off work.

Location also plays a major role, with access to oral health care significantly more limited for those living in rural areas. In North Carolina, dental providers are highly concentrated in urban centers; 98+ of the state’s 100 counties are designated as Dental Health Professional Shortage Areas (dHPSAs) by the Health Resources and Services Administration (HRSA).

Why School-Based Dental Programs for North Carolina?

The need is apparent, and while efforts to improve and sustain surveillance and evaluation in oral health care have been undertaken in North Carolina, the state lacks an adequate system to provide direct preventive services and closed-loop referral for comprehensive oral health care for at-risk populations. School-based dental programs can fill critical gaps in that system by meeting people where they are and reducing barriers to care influenced by the social determinants of health.

Increasing Access, Improving Outcomes

More than 2,500 school-based health centers (SBHCs) are operating in the United States, with only an estimated 28 percent having an oral health care provider on site, according to a report in Health Affairs.

The research increasingly supports the effectiveness of these programs improving access and oral health status among U.S. children. A 2021 study published in the Journal of the American Dental Association (JADA) determined that bringing cavity-prevention programs directly into school settings reduced cavities by 50 percent, after only six visits.

“Our hygienist who works more directly in the mouth is seeing a huge improvement in many of the children that are returning for repeat visits,” said Rachel Stewart, a registered dental hygienist who works for the East Carolina University School of Dental Medicine on a school-based initiative in Bertie County, North Carolina. “Their oral hygiene is improving, they’re taking more pride in their teeth, and their teeth are looking cleaner and better.”

A 2016 study of school-based dental sealant programs also demonstrated similar effectiveness among schoolchildren in low socioeconomic areas.

School-based dental programs are cost-effective, too. A recent report concluded that “the cost to place sealants on a child in a SBSP [school-based sealant program] is approximately $100 compared with the lifetime cost to maintain a tooth that develops caries, which can exceed $2,000.”

Researchers have also estimated that implementing a national school-based caries prevention program “could reduce Medicaid spending on children’s oral health by as much as one-half.”

Dental Hygiene Workforce

North Carolina’s oral health care workforce is well-equipped to provide preventive services in school-based settings. Dental hygienists in North Carolina are highly trained, skilled, and engaged, and there is ample opportunity to leverage this expertise and experience in school-based dental programs.

Recent regulatory changes, including a change to Rule 21 NCAC 16W .0104, co-sponsored by NCOHC in 2020, aims to provide greater opportunity for dental hygienists to deliver preventive services in high-need settings such as school-based programs. These changes allow for dental hygienists to deliver preventive services in high-needs settings without a prior examination by a dentist, therefore amplifying service delivery and decreasing administrative burden. Other potential legislative changes, such as increasing the dentist to hygienist supervision ratio, could also prove similarly helpful.

The Next Step

Recently, The Duke Endowment has partnered with the Blue Cross Blue Shield of North Carolina Foundation and the Blue Cross Blue Shield of South Carolina Foundation to expand school-based dental programs across the Carolinas. Collectively investing more than $35 million, these groups are supporting dental safety-net health centers in implementing school-based dental programs in North Carolina and South Carolina.

“This initiative is a revolutionary opportunity to increase access and equity and improve oral health outcomes among schoolchildren in the Carolinas,” says Dr. Brian. “With the support of The Duke Endowment, the Blue Cross Blue Shield of North Carolina Foundation, and the Blue Cross Blue Shield of South Carolina Foundation, North and South Carolina can make significant strides in reducing barriers to oral health care and improving oral health outcomes for at-risk populations.”

Get Involved

If you are an oral health care provider or administrator interested in learning more about expanding your practice to serve your communities’ children in school-based settings, we invite you to join us for our second free online informational session on September 14th, 2021. We had a fantastic info session on July 27th, so make sure you don’t miss out!

In these sessions, in addition to learning about opportunities for community impact through school-based oral health programs, participants will have a chance to learn about the application process and the deadline for funding, as well as hear directly from current grantees about their experiences.

In addition, following the live, interactive learning sessions, participants interested in applying for the next cohort will have an opportunity to engage in 1:1 coaching where you’ll dive into your program ideas and innovative approaches to strengthen your application.

To reserve your spot in a virtual informational session, please click here to register.

Nearly a year ago, NCOHC launched a COVID-19 oral health access map. As dental offices transitioned to only offer emergency services — and while health professionals worked to figure out how to best ensure provider and patient safety — our staff wanted to make sure that those who needed care weren’t left without any idea where to go.

There were several reasons why NCOHC hoped to highlight facilities offering emergency care across North Carolina. First and foremost, tooth decay and gum disease aren’t going to wait for the pandemic to subside. And, as anyone who has ever suffered from a toothache knows, when you have an oral emergency, you want it taken care of fast.

We also know that so many people with dental emergencies seek care at their local hospitals, which often are not equipped to handle that type of care. Even in a non-pandemic world, it is important to divert these patients to facilities that can address their concerns, rather than offer temporary solutions. Especially during a pandemic, however, reducing demand on hospital staff wherever possible is absolutely critical.

Our staff decided that a centralized map would be helpful to anyone who needed care, but didn’t know where to go. We thought a map would be a good resource, but we certainly didn’t think that more than 31,000 people would have viewed it nearly one year later.

But it makes sense. There wasn’t any centralized resource to use to find a provider near you—especially if you need to find affordable options that accept Medicaid or offer care on sliding fee scales.

Now that most offices are open for routine care again, NCOHC has decided to make the Access Map a permanent resource, displaying useful information beyond operating status. If you navigate to the map, you can see hours of operation, service type (kids and adults), and more.

Additionally, in the coming months, NCOHC staff will be updating the map with more information, such as the availability of translation resources.

What do you want to see on the NCOHC Access Map? We are looking for feedback as we continue to develop this resource. Take a moment and fill out our survey with any suggestions you have.

Looking for other ways to get involved? Head over to NC4Change today!

Last year, soon after the COVID-19 pandemic reached the United States, those of us at NCOHC were working to devise plans in how we would work to contribute to the public health response. We came up with a couple of ideas, including the creation of our safety-net access map and the launch of the NCOHC Teledentistry Fund.

We partnered with the Blue Cross and Blue Shield of North Carolina Foundation (BCBSNC Foundation) to launch the Teledentistry Fund, awarding up to $60,000 in grants for safety-net dental providers geographically spread across NC. So far, the fund has allowed 14 safety-net clinics to purchase teledentistry software, enhancing their ability to provide a wide variety of services with their communities without risking the health of patients and providers alike.

A year later, and we have been blown away by the results.

We recently sat down (virtually) with just a sample of the oral health professionals who received Teledentistry Fund grants to hear about their experiences. Check out the video below to learn how the software helped them navigate the pandemic, and what kind of future they see for remote care technology in a post-pandemic world.

 

This month NCOHC welcomed a new Program Coordinator. As Sarah Heenan joins the team, we sat down with her to ask a few questions about who she is and what brought her to the world of oral health.

Tell us a little about your background, where you are from, and your educational path.

I am from the Washington, D.C. area originally. I moved to Raleigh in 2004 to pursue a degree in history from Peace College, an all-women’s college at the time. I knew that my life’s work would be realized by working with people from all different life experiences, cultures, and backgrounds. Both personally and professionally, my time at Peace College led me down a road through the higher education landscape, helping students navigate their experiences while advancing the mission of the university. This direction helped me see value in gaining my Master of Arts in Higher Education at Appalachian State University, and eventually I ended up at North Carolina State University. There I learned the value of large public land grant institutions and the value of partnership with statewide organizations to provide needed resources to the people of North Carolina. My eyes were opened to the idea of shifting to the nonprofit world, where making a difference and changing necessary landscapes is at the forefront of the work.

What professional accomplishment before coming to NCOHC are you most proud of?

Building many relationships with both internal colleagues and external partners. A recent partnership I am most proud of is the development and management of the Off Campus Consortium group at NC State. I managed relationships between private off-campus partners and the university to provide the most direct and trusting housing resources to students.

What originally drew you to working in the oral health space?

Making a difference in our society by creating change and helping to provide needed services to the residents of North Carolina.

What has been the most rewarding part of your work with NCOHC thus far?

Working with the staff and learning about all of the work the Oral Health Collaborative engages in to create systemic changes in our state.

What are the biggest challenges that you see facing access and equity in oral health care in North Carolina?

Barriers to access due to the social determinants of health.

What do you enjoy doing when not working?

I enjoy spending time getting my hands in the dirt and working to create useful and beautiful garden spaces for my family and friends to enjoy. When I’m not in the garden, I’m generally building useful furniture made out of scrap materials. My two dogs, Oliver and Sage, and my partner, are always along for wherever the adventure may take us. In the time of the pandemic, because travel was not an option, we have enjoyed watching traveling shows and dreaming about getting overseas when it is safe to do so again.

What do you want our membership to know about you?

That I am a passionate individual who loves people and working hard to make systems more efficient.

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.

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.

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.

Oral health care price estimates were gathered from newmouth.com

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.

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.

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!

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.”

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.

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.

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!

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!

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.

“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!