A multifaceted approach to increase access to oral health care one step at a time.
Subject: Oral health (Forecasts and trends)
Author: Jacobs, Gary L.
Pub Date: 07/01/2008
Publication: Name: The Dental Assistant Publisher: American Dental Assistants Association Audience: Academic; Trade Format: Magazine/Journal Subject: Health; Science and technology Copyright: COPYRIGHT 2008 American Dental Assistants Association ISSN: 1088-3886
Issue: Date: July-August, 2008 Source Volume: 77 Source Issue: 4
Topic: Event Code: 010 Forecasts, trends, outlooks Computer Subject: Market trend/market analysis
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 203279803
Full Text: Connecticut is the wealthiest state in the nation on a per capita basis. Yet, dental-related health problems are the leading cause of absenteeism for school children. "At least 1 million Connecticut residents, and possibly as many as 1.5 million--more than one-third of the State--lack dental insurance." (1) The realization of these facts provided the impetus for a collaborative effort to address access to care for the underserved populations. Thanks to the many devoted professional and nonprofit health organizations motivated to this cause Connecticut has taken many steps forward in this noble effort. Occasionally, we have taken a step or two back in our climb, but persistence has been the key. The persistence of volunteers in the Connecticut State Dental Association, Connecticut Dental Assistants Association, Connecticut Dental Hygiene Association, Connecticut Department of Public Health, the Connecticut Health Foundation, Connecticut Oral Health Initiative and others spearheaded this initiative as a cohesive group with a common goal. The coalition is made up of a multitude of health care representatives who insisted on the inclusion of oral health as part of the overall access to health care issue.

Step 1: State Dental Practice Act Changes

Legislative changes to the Dental Practice Act included language to foster licensing of foreign-trained dentists while increasing the supply of dentists providing care to the underserved. The foreign applicant must hold a diploma from a foreign dental school and pass written and practical examinations. In addition, the applicant must complete at least two years of graduate dental training as a dental resident in an ADA CODA accredited program and at least two years of fellowship training in a community- or school-based program.

Recent legislative proposals also address tuition forgiveness programs to dental graduates who work in public dental settings providing care to the underserved. This may entice dental students who are burdened with heavy student loan debt to work off part or in some cases the entire balance of their education costs through time invested in service to those in need.

Step 2: Raise Medicaid Reimbursement Rates

"HUSKY" is Connecticut's Medicaid and SCHIP Program for Children. "The acronym 'HUSKY' stands for 'Healthcare for UninSured Kids and Youth.' It is a stretched allusion to the University of Connecticut's mascot, and like most sport teams, the HUSKY program has seen its share of wins and losses." (2)

In a 2006 study, only 27 percent of persistent "mystery shoppers" were able to get a preventive dental appointment for a HUSKY child. (3) Two-thirds of children enrolled in HUSKY for all or any part of 2004 received no dental care. (4) Even among children continuously enrolled in HUSKY in 2005, the best of circumstances, over half received no dental care. (5)

"A coalition of dental professional associations (including dentists, hygienists, and assistants), oral health advocates and others has been working to improve access. A lawsuit was filed against the State of Connecticut over seven years ago contending that the low reimbursement rates limited access and was a violation of Federal Medicaid law and regulation. After a considerable effort, in June of 2007, the Connecticut legislature voted to add $20M for dental services in HUSKY, on top of the estimated $17M already being spent. The State also agreed to settle the lawsuit and according to public statements the settlement agreement would result in a redesigned HUSKY dental care system that would include:

* "New reimbursement rates high enough to attract many new providers, starting no later than July 1, 2008,

* "A 'carve-out' of dental services to be managed by a single 'Administrative Service Organization' (ASO) on a nonrisk basis, that would replace the current four Managed Care Organizations (MCOs) and their three dental management subcontractors, and

* "Implementation of the new dental 'carve-out' system on July 1, 2008, one year after the funding was approved." (6)

Step 3: Improve Provider Recruitment

Attracting and retaining providers in the HUSKY program is a major obstacle in itself. The providers that are willing to participate have been discouraged by the complicated and time-consuming application process. The process was cumbersome to apply to each of four individual MCOs with no single administration to act as a clearing-house for applicants. In addition, participants and their office staff were simply overwhelmed by the reimbursement process. These factors compounded by low reimbursement rates hindered participation.

Will the increased reimbursement rates under the lawsuit settlement be enough to encourage provider participation without streamlining the process? Simplifying the process has become an initiative in correlation with the increased funding provided by the lawsuit settlement. The management of dental services by a single "Administrative Service Organization" will foster the process, but the focus will be on the efficiency for application and reimbursement submission to minimize staffing hours in the dental office. Eliminating these deterrents will more likely increase the successfulness in participation recruitment and retention of providers.

The Connecticut State Dental Association has taken the lead in addressing this issue by proposing an assistance call line for potential providers and current providers. An information line would be devoted to assisting the dental community with questions and providing direction with application procedures.

Step 4: Make Patient Access to Oral Health Care Accessible

The Connecticut Public Health Department studied the distribution of dentists throughout the state and found an uneven distribution that compounds the accessibility issue. Furthermore, cultural and educational barriers still exist and hamper accessibility to oral health care. These barriers are very real to our vulnerable populations and may include:

* conflicts with jobs and appointment times;

* language barriers;

* and education/culture.

The underserved population includes many "working poor" families that have to closely balance economics and needs. It is difficult for populations of higher socioeconomic status to understand or relate to this necessary prioritization of needs. The low wage occupations frequently held by this vulnerable group usually do not readily provide time off for preventive care. This adds a dimension to their decision process in the prioritization of needs because they might be in fear of losing their jobs and this may be a factor that holds more weight during downturns in our economy. Transportation is also a major issue, especially, if Medicare providers are not evenly distributed geographically.

Language differences can be an intimidating barrier, but this may be compounded when a patient has to complete medical and dental forms in an office.

Utilizing a "human needs" approach to address the barriers closest to our target population can only foster any initiative to increase access to oral health care.

There may be comfort in numbers to ease the intimidation factors in a dental office. Patients should be encouraged to invite family members and/or friends along to dental appointments to help overcome language and/or cultural barriers to care.

Education and culture often influence our decisions in later life on how we prioritize oral health care. To achieve lifelong healthy habits the educational process on oral health and its importance needs to start during the developmental years. The Connecticut Department of Public Health has spearheaded a pilot early childhood education program for grades K-12. The comprehensive health education program includes oral health education. (7)

Step 5: Expanded Functions Dental Auxiliary

The Expanded Functions Dental Auxiliary has to be part of any successful access to oral care initiative. EFDA is a proven means to reach a greater number of patients through efficiency in time management and cost reduction in providing dental services.

Expanded Functions Dental Auxiliaries have been utilized by foreign countries and branches of the U.S. military for years with proven success in providing dental treatment to greater numbers with efficiency and reduced overhead costs to the practice. In addition, states that have some form of Expanded Functions Dental Auxiliary are in the majority and some have been utilizing EFDA for over 30 years.

Labor market statistics through 2012 for dental assistants in Connecticut show a steady growth in demand with an annual growth rate of 57 additional positions. However, the projections are for 154 annual openings. This means that an estimated 97 dental assistant positions are vacated each year. (8) This employee turnover is very disruptive to a dental team and a management nightmare for public and private settings. The lack of job satisfaction has been deemed the main reason for the turnover of dental assisting professionals. This has become a national concern that the American Dental Assistants Association and Dental Assisting National Board task force has addressed with a proposed career ladder to improve job satisfaction and retention of dental assistants in the profession.

Currently, Connecticut has a feasible EFDA legislative proposal that has culminated after over three years of collaborative work. The legislative proposal has a built-in career ladder for both on-the-job-trained dental assistants and dental assistants who graduate from a CODA accredited program. The proposal also includes sound curriculum to provide competent EFDAs through education programs offered at institutions with an existing CODA accredited program.

The curriculum is arranged to accommodate working dental assistants who want to further their careers, but can't realistically attend full time day classes. At the same time, the passage of this legislation will assist in defining the Dental Practice Act for dental assistants and increase standards for public safety. This proposed legislation is an opportunity for everyone to win, especially, the underserved population in need of oral health care.

Expand school-based dental programs in combination with EFDA to provide efficiency of delivery and direct delivery to the target population. This system can truly break the barriers and make oral health care accessible to underserved children.

In the absence of unlimited funding there is no magical answer to I address access to oral healthcare. However, the culmination of these steps taken in Connecticut should have a positive impact of access to oral care.


(1) Poitras, Colin, Dental Needs Unmet, The Hartford Courant, April 15, 2008

(2) Milkovic, Marty, Executive Director, Connecticut Oral Health Initiative

(3) State of Connecticut, Department of Social Services Mystery Shopper Project, Nan Jeannero and Kerry McGuire, Mercer Government Human Services Consulting, Phoenix, November 2006

(4) Beazoglou T., Douglass J.M.. HUSKY A Dental Care: Financial Strategies. Policy Brief. Connecticut Health Foundation, January 2006

(5) Dental Care for Children in HUSKY A: Methods and Findings, Connecticut Voices for Children, October 2006

(6) Milkovic, Marty, Executive Director, Connecticut Oral Health Initiative

(7) Wilson, Ardell, D.D.S., M.P.H., Director, Office of Oral Public Health, State of Connecticut Department of Public Health

(8) Connecticut Department of Labor, January 2005

Gary L. Jacobs, CDA, RDH, MPA

Gary L. Jacobs, CDA, RDH, BS Ed., MPA, is a resident of Clinton, Connecticut and currently serves as Connecticut Dental Assistants Association President and holds a seat on the ADAA Council on Legislation. He has also held the positions of CDAA Vice President and President Elect and has actively participate on the following Committees: EFDA Curriculum; Legislative Task Force; and Ad hoc Access to Oral Health Care with the Connecticut Department of Public Health to serve and promote the Dental Assisting Profession.

After obtaining his Associates Degree in Health Science from Tunxis Community College in 1980, Mr. Jacobs attended Central Connecticut State University to achieve a B.S. in Dental Education. In the fall of 1989 he began his graduate studies at the University of Hartford's Barney School of Business where his studies culminated with a Master of Public Administration Degree. He is currently Associate Professor of Dental Hygiene and Dental Assisting at Tunxis Community College in Farmington, CT.
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