boom times for dentists, but not for teeth new york times october 11, 2007
TRANSCRIPT
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New York TimesOctober 11, 2007
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Health History and Oral Cancer Screening Caries Check, Clinical and Radiographic Periodontal Assessment
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27% of Children have untreated disease
29% of Adults have untreated disease
Data higher than 1980 and significantly higher than 1999
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Factors Related to Disparities in Access to
Oral Health Care
Harvey Weingarten DDS
University of Notre Dame
February 2008
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Many poor, lower income families don’t have any insurance, cash or governmental entitlement programs
Access to care is an issue even with those who can afford dental treatment
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• In 1982 we had 5,750 graduates of dental school
• In the last fifteen years 7 dental schools have closed their doors
• In 2003 we had 4,400 graduates of dental schools
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Average age of Dentist is 49 years old
Beginning in 2012 more dentists will be retiring than graduating
States need to liberalize expanded auxiliaries laws
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DDS◦3,213 practicing in Indiana◦Statewide Ratio 1:1,952 people
RDH◦3,661 practicing in Indiana◦Statewide Ratio 1:1,713 people
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78
32
0
10
20
30
40
50
60
70
80
Percentage
N=451 of 498 (91%) of IUSD grads from 1994 – 1999 (contacted in 2003)
In State Students Out of State Students
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Hamilton County 1: 999Marion County 1:1,370Boone County 1:1,407Floyd County 1:1,469Howard County 1:1:1491
Warren County 1: 8,785Switzerland County 1: 9,718Crawford County 1:11,216Starke County 1:11,467Ripley County 1:14,855
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Population 266,160
137 Dentists or 1 per 1,943
231 Hygienists or 1 per 1,152
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5000000
5200000
5400000
5600000
5800000
6000000
6200000
6400000
'90 '92 '94 '96 '98 '00 '02 '04 '06
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0
500
1000
1500
2000
2500
'90 '92 '94 '96 '98 '00 '02 '04 '06
Sources: Indiana Professional Licensing Agency & US Census Bureau
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1400
1450
1500
1550
1600
1650
1700
1750
'90 '92 '94 '96 '98 '00 '02 '04 '06
Sources: Indiana Professional Licensing Agency & US Census Bureau
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DHPSA designations enable $25K-35K annual tax free loan repayment plus salary – incentive for new graduates to practice in rural and inner city underserved areas
More Counties qualify than are designated
Ratio of 1 dentist per 5,000 or more people
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In 32 of 92 counties (35%) >75% of land is farmland
46 of 92 counties (50%) are officially
designated as rural Nearly 2/3 of Indiana’s
23 million acres are farmlands◦ 5/92 counties >90%
farmland◦ 6/92 counties <33%
farmland
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11 of 92 counties do not have any Medicaid providers
52 CHCs with 25 Dental Clinics (13 are in Indianapolis)◦ See attached table listing community health centers and dental
clinics)
Distribution◦DDS with smallest patient pool are in affluent areas◦DDS with largest patient pool are in rural and
impoverished inner-city areas
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Limitations due to lack of current epidemiological data◦ Last statewide survey 1992-93
No data on the oral health of special population groups; adults; elderly; disabled
Marion County survey of children conducted in 2000 by IUSD for MCHD
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Services Provided March 2003 - Dec
2006
10,938 children examined to date
16,928 sealants placed
7,831 Fluoride varnish
1,919 BW x-rays (6-14 yrs)
674 days at 575 sites in Indiana
Children with untreated carious lesions: 52%
35% = non-urgent17% = urgent
All are children from low income families
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66
73
62
64
66
68
70
72
74
Urban Rural
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30
13
25
18
0
5
10
15
20
25
30
Urban Rural
non-urgent urgent
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Economic Issues Number of Dentists / Ratio of Dentists to
Population Geographic distribution
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Unfunded Unaccepted Inaccessible Unconvinced Unmotivated Powerless
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6.2 million Hoosiers
From 2000 to 2004 Indiana lost 138,800 jobs
Change: manufacturing jobs, service sector and small business (less likely to provide dental insurance to employees)
Food Stamps and Temporary Assistance for Needy Families (TANF) have nearly doubled in 5 years
Highest per capita rate of medically bankrupt families (>77,000 Hoosiers)
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>30% of Hoosiers who are uninsured are employed by companies that offer coverage, but it’s not affordable, or they are not eligible (part time/seasonal)
Indiana health insurance rates have increased by double digit rates for the last four years, higher than the national average.
Many Hoosier small businesses have dropped health and dental insurance benefits
Source: Kaiser Family Foundation 2004
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$4.5 Billion annual budget Dental expenditures = 2.5%
21-30% of children enrolled received dental care in a given year
Reimbursement rates are higher than the national norm
24% of Indiana children 0-18 are covered by Hoosier Healthwise
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24% children 0-18 years (nat’l 26%) 9% women 19-64 (nat’l 9%) 4% men 19-64 (nat’l 6%)
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Undocumented Immigrant Children: eligible only for Pkg E Medicaid (E=Emergency only – no dental care unless life threatening)
Indiana Population 6,271,973 Indiana population July 2005 Estimated 4.4% are Hispanic = 275,966 160,000 Hispanic citizens 65,000 Undocumented immigrants* Other estimates 50,000 – 10,000
* Pew Hispanic Center 2004
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91% of children <poverty level 39% Hispanic 30% enrolled in Hoosier Healthwise vs
55% in other schools 29% had severe caries vs 17% in other
schools
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Framework for Service-Learningat Indiana University School of Dentistry
Source: YoderKM, J Dent Education ,Feb 2006
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Use service-learning to reduce two common barriers:
Medicaid acceptance: cause students to see, and reflect on, the extent of the effects of disparities in access to care
Dental services for young children: offer service-learning rotations in the 1st & 2nd years that allow students to work with very young children (ie. Head Start)
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2
12
59
17
10
0
10
20
30
40
50
60
Percentage
>5 yrs 4 yrs 3 yrs 2 yrs 1 yr
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Accelerate recruitment of candidates from underserved rural counties and minority populations
Attempt to retain a greater number of graduates in Indiana
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Integrate community based service-learning throughout the curriculum and structure it to enhance clinical and cultural competency skills development
Create a new option or expand the extramural program to encourage exploration of alternative practice settings, (Community health centers, US Public Health Service, International programs)
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Continue Counseling students about potential financial incentives for staying in Indiana and practicing in underserved areas & lobby to develop other options
◦ Health Service Corps – loan repayment for working in community health centers ($25 – 35K year tax free)
◦ Explore possibilities for loan repayment options for private practice models serving underserved areas (Washington State)
◦ Lobby for higher Medicaid reimbursement rates for dentists serving special needs populations and underserved geographic areas (Minnesota model)
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Sister Maura Brannick Chapin Street Health Center
IUSB Dental Education Clinic
Indiana Health Centers
Heart City Dental Clinic
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Qualify
Working Poor Clinic
$10 Co-pay per appointment
Reduced Lab Fees
Volunteer DDS and Hygienist
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Educational Clinic
Reduced Fees
Will file all insurance programs
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Open to patients of Heart City Health Center. Medicaid and referral from Elkhart Hospital
Income Based Sliding Fee Schedule- 40% of U and C Grants from local business and Trustee
office