“I’m confused” – A Florida dentist tackles recent statements made by ADA in regards to access to dental care

By Frank A. Catalanotto, DMD
August 5, 2013

Only a couple of months ago, the American Dental Association acknowledged that our nation is facing a “dental health crisis” and agreed that much more must be done to improve access to care. (1) For this reason, I am confused by recent statements released by the ADA about the access problem.

These statements dismissed the conclusions of a report by the Pew Children’s Dental Campaign and expressed doubt that “the size of the dentist workforce” is playing a major role in access disparities. To support its view, the Association pointed to data from Mississippi showing that the percentage of Medicaid-enrolled children receiving dental care has risen even though the state has the nation’s most severe dentist shortage.

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While I would agree that dental workforce is just one of several factors that can influence access to oral health care and overall oral health, the Association is conflating two distinct challenges. The first challenge is the size of the workforce, and the second challenge is the portion of dentists willing to treat Medicaid enrollees. Although both of them matter, the primary factor shaping access to low-income residents is the number of dentists within a state who participate in Medicaid.

Yet the overall number of practitioners is still meaningful because access is more likely to be strained whenever the available pool of dentists is insufficient to meet the need for care. If the overall pool is inadequate, it intensifies the need to find practitioners who are willing or able to see underserved people. This is not simply Pew’s conclusion; it is also the conclusion reached by others who have examined this problem. For instance:

• In a 2010 report, for example, the Walsh Center for Rural Health Analysis identified “[p]ersistent and worsening shortages of oral health care providers in rural areas” as one factor driving people to hospital emergency rooms “for problems that might have been prevented.” (2)
• Last year, Dr. D. Gregory Chadwick, dean of the East Carolina University Dental School, wrote an article about the state’s dental workforce and observed that “access to oral health care services in many areas of the state remains problematic.” Although he noted that multiple factors shape the access problem, Dr. Chadwick noted that the “availability of a dentist and the dental team is fundamental” to meeting the state’s dental care needs. (3) This very perspective is what has driven the opening of several new dental schools over the last decade.

To back up its statements against authorizing midlevel dental providers, ADA president Robert Faiella also noted, “At the federal level, Congress has declined for three straight years to appropriate money for midlevel programs.” What he is referring to is funding to study various types of dental providers. I might also speculate that the reason Congress has not funded such programs is due to the oppositions from the ADA and their representatives in Congress. The ADA’s opposition to this seems counterintuitive given its creation a new model, the “community dental health coordinator,” or CDHC, which would benefit from this blocked funding. The CDHC is a key component of the Association’s “Action for Dental Health” campaign and could be studied alongside other models under this federal program, not to mention the states moving forward with pilot programs to evaluate how alternative dental providers increase access to care, including one housed at a dental school in Michigan.

In my state, Florida, we often see barriers to care. According to recent CMS data, Florida ranks at the bottom of the country in terms of the percent of Medicaid patients who have at least one annual dental visit, with only 25% of the enrolled patients having an annual dental visit. (4) Estimates are that less than 15% of Florida dentists participate in the state Medicaid program and this number could decrease with the full implementation of managed care, combined with very low reimbursement rates. (5) Our research team in Florida has submitted a paper currently under review that suggests that there are reasons other than low financial reimbursement and administrative hassles that prevent some dentists from participating in the Florida Medicaid program.

The results of these statistics include anecdotal reports of patients driving one to two hours to obtain care at the University of Florida Pediatric Dental clinic, which does accept Medicaid, because patients cannot find dentists in their local community who participate in the Medicaid program. There is little doubt in my mind that the small number of patients having access to care in Florida is a major factor in the large number of Medicaid patients who go to hospital emergency rooms for preventable dental conditions. (6)The bottom line to me is very clear – an insufficient dental workforce is one of several factors that influence access to oral health care both here in Florida and in many other areas across the country.

Frank A. Catalanotto, DMD, is a professor at the University of Florida’s Department of Community Dentistry and Behavioral Science in Gainesville, Florida.

Sources:

1. American Dental Association, “America's Dentists Launch Nationwide Campaign to Address U.S. Dental Crisis,” May 15, 2013 press release, http://www.ada.org/8607.aspx.
2. E.F. Shortridge and J.R. Moore, “Use of Emergency Departments for Conditions Related to Poor Oral Health Care,” Walsh Center for Rural Health Analysis, August 2010, http://www.norc.org/PDFs/publications/OralHealthFinal2.pdf.
   
3. D. Gregory Chadwick, “The East Carolina University School of Dental Medicine’s Approach to Dental Workforce Education and Reaching Underserved Areas,” North Carolina Medical Journal, (2012) 73:2, pp. 108-110, http://www.ncmedicaljournal.com/wp-content/uploads/2012/03/NCMJ_73205-web.pdf.
   
4. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-Periodic-Screening-Diagnosis-and-Treatment.html; link to 2011 dental data.
   
5. http://www.tampabay.com/news/health/dental-care-for-poor-florida-children-already-scarce-could-get-worse/2129320
   
6. http://www.floridaoralhealth.com/ER_Data