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IOM report eyes improving access to oral health care for vulnerable, underserved populations

Charged with assessing the current U. S. oral health care system, and in particular, its strengths, weaknesses and future challenges for delivering care to vulnerable and underserved populations, the Institute of Medicine Committee on Oral Health Access to Services released a 243-page report this morning, outlining its vision for the future and far-reaching recommendations for federal agencies, state governments and other stakeholders for improving access to oral health care.

Dr. Gist, ADA president, issues statement on IOM report

The ADA today released this statement by ADA President Raymond Gist on the IOM report, “Improving Access to Oral Health Care for the Vulnerable and Underserved Populations”:

“We welcome the IOM’s ambitious 243-page report on ways to improve the nation’s oral health care delivery system, and we look forward to reviewing it in greater detail. Based on the report’s summary, we agree wholeheartedly with many of its recommendations.  In fact many of them reflect policies and programs that the ADA has had in place for years.

“We have long said that Medicaid funding and administration must be improved and that adults must be covered. Federal and state governments must take steps to make it possible for the private practice community to increase dramatically its role in the oral health safety net. The federal government should increase its support for dental education, especially residency programs, and dental students, residents and faculty must be fully utilized in providing safety net care. And increased non-clinical support services, such as those provided by the ADA’s Community Dental Health Coordinator, are critical to a comprehensive system of care.

“To best accomplish these goals, governments, foundations and other stakeholders must include the private practice community at all stages of developing their policies and policy recommendations. Only about 2 percent of the nation’s dentists work in fulltime safety net capacities. The vast majority work in private practice, and this is unlikely to change in the foreseeable future.  Private practice dentists will continue to provide the majority of hands-on care to vulnerable populations.

“The IOM report mentions—without making recommendations—various dental workforce innovations that are either under way or under discussion.  The ADA continues to support exploring new ways to maximize the efficiency of the team system of delivering dental care. Our Community Dental Health Coordinator project is one example of this. However, we must restate our opposition to allowing so-called midlevel providers, to diagnose disease or perform such surgical/irreversible procedures as extractions. Everyone deserves a dentist.

“Virtually every shortcoming in the safety net has at its root a failure to understand or value oral health. When people, whether lawmakers, the media or the general public, understand oral health and the consequences of oral disease, their attitudes and priorities change. Awareness is on the rise, but we have far to go before Americans know enough to make the personal and policy decisions that ultimately will create a real safety net, one that prevents disease and restores oral health in people who seek healthier and more productive lives. We welcome the Institute of Medicine’s lending its considerable influence to our longstanding efforts to achieve that goal.”

“Improving Access to Oral Health Care for Vulnerable and Underserved Populations” (available online at www.iom.edu) states that millions of Americans are not receiving dental care because of “persistent and systemic” barriers that disproportionately affect children, seniors, minorities and other vulnerable populations and recommends changing funding and reimbursement for dental care; expanding the oral health workforce by training physicians, nurses and other nondental professionals to recognize risk for oral diseases; and revamping regulatory, educational and administrative practices.

The committee’s summary emphasizes that complex and numerous barriers to access include social, cultural, economic, structural and geographic factors, citing that:

  • In 2008, 4.6 million children did not obtain needed dental care because their families could not afford it.
  • In 2011, there were approximately 33.3 million unserved individuals living in dental health professional shortage areas.
  • In 2006, only 38 percent of retired individuals had dental coverage.

“Oral health care is one of those dimensions of our health care delivery system in which striking disparities exist,” said Frederick P. Rivara, M.D., M.P.H, committee chair, in the report preface. “More than half of the population does not visit a dentist each year. Poor and minority children are substantially less likely to have access to oral health care than are their nonpoor and nonminority peers.

“Americans living in rural areas have poorer oral health status and more unmet dental needs than their urban counterparts,” he continued. “Older adults, especially those living in long-term care facilities, have a high prevalence of oral health problems and difficulty accessing care by individuals trained in their special needs. Disabled individuals uniformly confront access barriers, regardless of their financial resources.”

Dr. Rivara, Seattle Children’s Guild Endowed Chair in Pediatrics and professor of Pediatrics, School of Medicine, University of Washington, stressed that the consequences of these disparities “have a strong influence not only on oral health but on overall health as well."

The report covers other issues including oral health status and utilization; workforce; oral health care settings; expenditures and financing and overall conclusions and a vision for improving access to care.

Recommendations call on the Health Resources and Services Administration to work with the public and private sectors to integrate oral health care into overall health care and to dedicate Title VII funding to increase recruitment of dental professional students from underrepresented minority, lower income and rural populations, and to develop community-based education rotations, dental residencies and training for treating underserved and vulnerable populations.

The report also asks state legislatures to amend state laws and practice acts to maximize access to care and asks states to set Medicaid and Children’s Health Insurance Program reimbursement rates at a level that increases provider participation in publicly funded programs and to provide case-management services and streamlined administrative processes.

The report asks Congress, the Department of Health and Human Services, federal agencies and private foundations to fund oral health research and evaluation related to underserved and vulnerable populations, including new methods and technologies (e.g., nontraditional settings, nondental professionals, new types of dental professionals and telehealth); measures of access, quality, and outcomes; and payment and regulatory systems.

The report further recommends that HRSA should expand the capacity of federally qualified health centers to deliver essential oral health services.

The study was sponsored by HRSA and the California HealthCare Foundation.