Oral Health Access Concerns: A National Issue and A Madison Perspective

Executive Summary and Findings

As part of the Health Quest community health improvement process, access to health care was designated as the number one health priority theme. Included in this priority was access to dental care -- a major unaddressed health problem for Madison. To learn more about the scope of the problem, the Madison Department of Public Health selected dental access as the strategic health care access issue.

To determine the demand and unmet need for dental services, existing community data along with several surveys (e.g., random sample of Dane County dentists survey, Madison Metropolitan School District (MMSD) school nurse survey, etc.) were used to identify a "picture of need" for the Madison community. The findings indicate that Madison has a major dental access problem.

1. Oral health has a profound impact on overall health, but the association of poor dental health and disease is largely overlooked. Oral health is part of one’s total health and the mouth is part of one’s body, but in terms of access issues, insurance status and health policies, oral health is viewed separately.

2. There is a critical need for dental health care by low-income and vulnerable populations in the Madison community. A significant percentage of Madison’s preschool and school children have untreated dental disease. Individuals and community agencies that advocate for them make hundreds of telephone calls each month looking for dental care.

3. Community dental resources have insufficient capacity to meet the demand for dental care for low-income and vulnerable populations. There are long waiting times for appointments, and limitations on dental services and on the numbers of patients that can be served.

4. Only 26% of eligible Medical Assistance (MA) recipients are receiving dental services in Dane County.

5. There is an ample supply of dental providers to serve Madison residents, but an inadequate supply of dentists serving uninsured and MA patients.

6. Despite the fact that Dane County exceeds suggested dental provider ratios, south central Madison has been designated as a dental Health Professional Shortage Area (HPSA).

7. As a designated HPSA site, the Harambee Dental clinic is eligible to employ National Health Service Corps (NHSC) personnel, but has insufficient funding to pay for a NHSC dentist.

8. There is an insufficient supply of pediatric dentists, only four in Madison, and three of the four dentists are accepting new MA children.

9. Patients and providers face numerous obstacles to receiving MA dental care. Patients may lack sufficient knowledge regarding their dental benefits, the importance of dental care (especially preventive care), and have difficulty finding dental providers. Providers object to low reimbursement rates, billing system red tape, and the number of no-show patient appointments.

10. A third of Dane County residents do not have dental insurance. This means that a third of the County’s residents are more likely to use episodic dental care and are less likely to utilize preventive services.

11. There is inadequate utilization and understanding of the value of preventive dental care.

12. Dental disease is a chronic problem among low-income populations. In addition to socioeconomic barriers, minority status is a significant barrier to receiving dental care.

13. Dental access is a national problem with a very real local impact. Community-wide solutions are needed to address the dental access problem.

The Institute of Medicine defines access to health and dental care as "the timely use of personal health services to achieve the best possible health outcomes." The most important test relating to dental access is "equity of access," - whether or not there are differences in the use and outcomes of dental services because of financial difficulties or other barriers to care. Dental access is associated with dental insurance and having sufficient dental providers in a geographic area. Utilization of the dental care system depends on: 1) predisposing
factors – race, gender, education, occupation, etc.; 2) enabling factors - income level, dental insurance, availability of dental personnel and lack of structural barriers such as telephones and transportation; and 3) need factors -understanding the importance or perceived need for dental services.

If dental problems are untreated, serious dental disease can occur which may have a detrimental effect on overall body systems. Heart disease, diabetes, pneumonia, premature birth, and systemic infections have all been linked to oral infections. Adult oral health concerns include periodontal disease, decay, and oral cancer. A child’s dental health status is an indicator of his or her overall health. Children suffer every day from chronic toothaches, acute pain, dental abscesses, disfigured smiles, and dysfunctional speech. For them, dental disease results in poor nutritional intake, missed time from school, poor learning, and behavior problems.

To determine the demand and unmet need for dental services, existing community data and several surveys painted a "picture of need" for the Madison community. The following information indicates a significant demand for dental health care which is not being provided:

• Over 400 telephone calls a month seeking dental care

• One out of five school children with untreated dental needs

• One out of four Head Start children in need of dental treatment

• A majority of surveyed school nurses reporting increases in dental needs among the children in their schools.

There are five community dental clinics providing limited dental services to low-income children and adults:

1. Harambee Dental Clinic (HDC) utilizes volunteer dentists to treat children and adults with dental needs (700 were patients served in 1999). HDC receives over 6,000 calls a year for patients needing urgent care. For non-emergency appointments, there is a three to six month wait.

2. Max W. Pohle Dental Clinic at Meriter Hospital serves 4,500 patients annually. Non-emergency waiting time for dental appointments is about three months when accepting new patients.

3. The Madison Department of Public Health’s Children’s Free Dental Clinic at Madison Area Technical College (MATC) provides comprehensive dental care to 150 low-income, non-MA, uninsured children per year.

4. The MATC Dental Hygiene Clinic uses students to provide preventive, education and therapeutic dental hygiene services to 2,200 patients annually. A minimal fee is charged for services and waiting time for appointments averages around one month.

5. The University of Wisconsin (UW) Dental Clinic offers limited treatment services for established adult, medically-compromised patients. The UW clinic is not accepting new MA patients.

Other community oral health resources include school-based and school-linked dental sealant programs. The Madison Department of Public Health and the Dane County Division of Public Health offer free dental sealant days at MATC, various community sites and cooperate with the Wisconsin National Guard "Guard Care" sealant program. These programs provide free sealants for approximately 100 to 200 children per year. "Seal Dane" is a school-based, free dental sealant program for low-income children in Madison and Dane County, administered by the Dane County Division of Public Health with funding provided by the Meriter Foundation. It operates on a part-time basis and is currently grant funded for up to two years.

There are three major barriers to dental health access: structural; financial; and cultural. Specific barriers in the Madison community are:

1. Availability of Dental Providers: Although the ratio of Dane County dentists to patients is almost twice the recommended standard, south central Madison has been designated as a dental Health Professional Shortage Area due to the large number of low-income residents and the lack of dental providers. Nationally and locally, the number of practicing dentists is declining.

2. Failure of Federal Programs to Provide Access: Medical Assistance is the health safety net for the poor, yet only 26.2% of eligible Dane County residents received any kind of dental service in 1999. Less than 1% of all MA expenditures go towards dental services.

• Obstacles for patients utilizing the MA program include: lack of information about eligibility and dental coverage, low number of MA provider dentists, lack of knowledge about the value of preventive dental care.

• Obstacles for MA Providers include: low reimbursement rates for providers, extensive paperwork and red tape, lack of patient compliance, and high "no-show" patient appointment rates.

• An overwhelming majority of surveyed dentists are providing donated and reduced rate services to underserved patients, and often do not bill for MA patients to avoid the burdensome paperwork and low reimbursement rates.

• The State Division of Healthcare Financing perspective reports that dental prices are increasing at rates exceeding physician rates, and despite a 5% increase in reimbursement rates, dentists are seeing even fewer MA patients.

3. Lack of Dental Insurance: People without dental insurance are less likely to have a recent dental visit, and are less likely to utilize preventive services. The uninsured are more likely to have episodic use of dental treatment services when an emergency arises. Approximately one third of all Dane County residents do not have dental insurance.

4. No Regular Source of Dental Care: Having a regular source of care means more dental visits especially for preventive dental care. A regular source of care increases the likelihood that MA children will use dental services. Many eligible MA patients do not have a dental "home" due in part to an insufficient number of MA provider dentists.

5. Low Dental Priority: In Dane County, 46% of the population have not visited a dentist or dental clinic within the last year because there was no reason to go ("no dental problems"). When asked what were "perceived barriers for patients (the dentist survey) and children (school nurse survey)" to obtain dental care, "low dental priority" was listed as number one by dentists and number two by school nurses.

6. Socioeconomic and Minority Status: A General Accounting Office (GAO) report on oral health concluded that "dental disease is a chronic problem among low-income and vulnerable populations." Analysis of key dental indicators indicates large disparities between low-income groups and vulnerable populations such as the homeless, minority groups, and higher income counterparts. These disparities were confirmed locally in the "Make Your Smile Count" survey of school children. The survey of area dentists found that 63% are serving non-English speaking patients, but only 10% overcome this barrier by providing translation services or by employing bilingual staff.

Access to dental care is a national and state problem with a very real local impact. Who owns this community problem? We all do. Who can solve this community problem? We all must! Hopefully, this report will mark the beginning of that community-wide solution.

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