GrantWatch Report Delivering Preventive Oral Health Services In Pediatric Primary Care: A Case Study The Washington Dental Service Foundation s investment has been paying off. by Dianne Riter, Russell Maier, and David C. Grossman ABSTRACT: Dental disease, the most prevalent chronic disease of childhood, affects children s overall health and ability to succeed. Integrating oral health into routine well-child checkups is an innovative and practical way to prevent dental disease. The Washington Dental Service Foundation is partnering with Group Health Cooperative, a large integrated delivery system, and other providers in Washington State to change the standard of care by incorporating preventive oral health services into primary care for very young children. This paper describes systemic and policy changes for engaging primary care providers in oral health, including provider training, expanding access to dental care, and reimbursement. [Health Affairs 27, no. 6 (2008): 1728 1732; 10.1377/hlthaff.27.6.1728] Dental disease is the most prevalent chronic disease of childhood. Dental decay is so widespread and the health effects so substantial that in 2000, the U.S. surgeon general classified dental disease as a silent epidemic. 1 A child with untreated dental disease has difficulty eating and sleeping properly because of pain, may experience a delayed ability to speak, and is at risk for further health problems. 2 Although dental disease rates had been declining over the past four decades for most Americans, the latest national survey indicates that the prevalence of dental decay in children s primary teeth is increasing. Among U.S. children ages 2 5, the prevalence of dental disease increased from 24 percent during 1988 1994 to 28 percent during 1999 2004. 3 In Washington State in 2005, 45 percent of low-income preschoolers had dental decay, based on a survey involving oral screenings. 4 Therateofdentaldecayincreasedoverthe 1994 2005 period: 38.3 percent of low-income preschoolers had dental decay in 1994, compared with 45 percent in 2005. 5 Treating severe cases of dental disease in a hospital operating room can cost $5,000 $7,000 per child. 6 In 2007 Washington State s Medicaid program spentmorethan$40milliontreatingchildren for dental disease. 7 Much of this cost could have been avoided if prevention had been a higher priority. Dianne Riter (DRiter@DeltaDentalWA.com) is a senior program officer at the Washington Dental Service Foundation (WDSF), in Seattle. Russell Maier is a family practice physician and residency director at Central WashingtonFamilyMedicineinYakimaandisaWDSFboardmember.DavidGrossmanismedicaldirectorfor preventive care and a senior investigator in the Center for Health Studies at Group Health Cooperative, in Seattle. He is also a professor of health services and an adjunct professor of pediatrics at the University of Washington, in Seattle. 1728 November/December 2008 DOI 10.1377/hlthaff.27.6.1728 2008 Project HOPE The People-to-People Health Foundation, Inc.
Innovative Approaches In Washington State Children s dental disease is a national problem, but innovative solutions are often best initiated by states and communities. In Washington State there has been a concerted effort to develop new ways to improve oral health for young children. The state s Medicaid program was one of the first to reimburse primary care providers for applying fluoride varnish on children s teeth. The Access to Baby and Child Dentistry (ABCD) program, a collaborative effort of public and private entities at the state and local levels, is increasing the number of Medicaideligible children under age six who are receiving dental care. 8 Early preventive and intervention services can yield positive benefits and lead to an increased likelihood of future preventive services and decreased dental-related costs. 9 Some professional organizations now recommend that children have their first dental screening by age one. However, traditionally, few children have had access to preventive dental care at that age, because many family dentists are not trained, or confident enough, to see infants and toddlers. Because primary care providers see young children eight times or more for well-child visits before age three, they are well positioned to deliver basic preventive oral health services. In 2000 the WDSF, a 501(c)(4) nonprofit organization, began evaluating options for preventing dental disease among infants and toddlers. To achieve oral health impact at the population level, the WDSF advocates for strategic systemic changes. Starting in 2001, the WDSF funded three pilot projects in Washington State that addressed oral health during well-child checks: (1) Seattle Children s Hospital s Healthy Smiles Project; (2) ABCD- Expanded, developed by Spokane Regional Health District; and (3) Kids Get Care, operated by Public Health Seattle and King County. These initial efforts identified early adopters willing to champion oral health and ledtothedevelopmentofnewmaterialsfor physicians to use, including a risk assessment tool and pocket guide to help identify decay. The pilots also showed that there were major barrierstoovercomebeforepreventiveoral care could be routinely delivered in primary care offices. Engaging Physicians Support Physician focus groups were convened to determine how oral health could be addressed during well-child checks. The physicians identified three needs: training on how to deliver the services; availability of follow-up dental care, especially for Medicaid-insured patients; and reimbursement for providers delivering the services. Gaining the support of the medical community was essential to convincing a broader audience that oral health is an important health issue. As one physician said, It s time we stopped looking right past the teeth to check the tonsils. Several oral health champions were identified in each professional medical group. In 2002 the Washington Academy of Family Physicians and the Washington State Medical Association adopted resolutions urging physicians to address the oral health of mothers and their young children. Oral health training and support. Physicians can learn to identify children at risk for dental disease who need to be referred to a dentist for follow-up care. 10 Drawing on the best practices developed in the pilot projects, the WDSF developed a continuing education curriculum on oral health for physicians and staff. To establish credibility and to respond to clinically oriented questions, dentists or physicians under contract with the WDSF conduct the training. It includes a presentation on theimportanceoforalhealth,therolesforprimary care providers in preventing dental disease, useful tips for delivering oral health services during well-child checks, and when to make dental referrals. The ninety-minute didactic session features a hands-on demonstration of oral screenings, risk assessments, and fluoride varnish applications. Brochures and bookmarks are disseminated to deliver consistent health messages to HEALTH AFFAIRS ~ Volume 27, Number 6 1729
families. These materials, along with posters, help keep oral health visually prominent in medical offices. The training also includes informationonbillingmedicaidandwashington Dental Service and ordering supplies. WDSF staff and consultants provide ongoing technical assistance. To ensure that new physicians are trained to include oral health in their practices, the WDSF sponsored an elective course on oral health for first- and second-year medical students at the University of Washington, beginning in 2005. The foundation, together with the Oral Health Foundation (located in Boston, Massachusetts), Connecticut Health Foundation, and other philanthropies, also sponsored the development of the Society of Teachers of Family Medicine s oral health curriculum for family medicine residents, Smiles for Life, which has been used nationwide. 11 Ensuring availability of follow-up dental care. Physicians identified lack of access to dental care as one barrier to addressing their patients oral health. Physicians were concerned that if they identified dental problems, they would not have a place to refer patients for follow-up dental care, especially thosecoveredbymedicaid.thecollaborative ABCD program helped address this issue by working to expand access to dental care for Medicaid-enrolled children under age six. The program operates in more than 75 percent of Washington counties, where 93 percent of the state s Medicaid-enrolled children under age six reside. 12 The University of Washington trains dentists to provide preventive and restorative dental care for young children. Local health departments identify and enroll eligible children in ABCD and link them with trained dentists. The state Medicaid program provides enhanced reimbursements to such dentists, and the WDSF provides three-year start-up grants to local health departments to support the launch of local ABCD programs. Data demonstrate that ABCD has contributed to an increase in dental access for young children. Between 1997 and 2007, the Medicaid dental utilization rate for children under age six increased from 21.1 percent to 36.8 percent. 13 Reimbursing medical providers. Physicians identified reimbursement as a critical factor in their providing preventive oral health services. In 2004 Washington Dental Service, the nonprofit funder of the WDSF and the state s leading dental benefits company, began to reimburse physicians for delivering oral screenings and applying fluoride varnish. The Washington Medicaid program had been reimbursing primary care providers for fluoride varnish since 1998. Although that was an important step, in 2000 only 145 Medicaidenrolled children under age six received this service. 14 To further promote prevention and early intervention, the logical next step was to pursue Medicaid reimbursement for primary care providers who deliver oral screening and oral health education (a service that WashingtonMedicaidreimbursesthroughtheABCD program). It was necessary to lay a foundation for this policy change by increasing public awareness of oral health s importance and convincing key audiences such as legislators and stateagenciesthatoralhealthisbothapersonal and a community responsibility. Building Political Will To gain the approval of the legislature and governor, the WDSF designed a campaign including radio, television, and print advertising explaining that children s oral health matters. Other credible organizations, such as medical associations and hospitals, partnered withthewdsfonitscampaigntopromote the importance of children s oral health. The foundation worked to generate media interest and helped place several opinion pieces in newspapers statewide. To build public awareness about the importance of preventing dental disease, materials were distributed to parents through pharmacies and state and local health agencies. Instead of developing a stand-alone bill, the WDSF and other child advocates made a strategic decision to include the proposal to broaden the types of oral health services reimbursed by Medicaid as part of broader legislation to increase health care coverage for children. The WDSF spent considerable time 1730 November/December 2008
building support among key legislators and actively engaging stakeholders including physician groups, hospitals, and dental and children s advocacy groups. In 2007, thanks to the work of a broadbased coalition, the legislature and the governor approved the legislation to ensure that all children in Washington State get comprehensive health care coverage, regardless of income or citizenship. This legislation also specified that Medicaid reimburse trained primary care providers for oral screening and oral health education. Reimbursement for applying fluoride varnishwassetat$13.66;forfamilyoralhealth education, $27.58; and for a periodic oral evaluation, $29.46, for a total of $70.70. 15 Demonstrating Best Practices In 2007 a demonstration project was launched to develop best practices for including oral health in well-child visits in a large medical system. The WDSF partnered with Group Health Cooperative, a consumergoverned, nonprofit health care system that serves more than 568,000 members in Washington State and Idaho, to implement a threeyear demonstration project in six of its primary care medical centers in Washington. Nationally, this is the first comprehensive project that pairs a large health care delivery system with public and private dental payers. If the project proves successful, the ultimate goal is to expand it to all Group Health primary care centers statewide. The goal of this collaboration is to develop a clinical, business, and operating model for providing oral health care as part of standard medical care for infants and young children. The project provides real-world experience; feedback from physicians, staff, and parents; andinformationaboutbestpracticesforcreating this new standard of care. Washington Dental Service covers the costs of the preventive services for its eligible subscribers who are also Group Health members. Medicaid covers the costs of these services for its enrollees. To remove any financial barriers related to patient fees, during the demonstration project the WDSF is paying for preventive services to be delivered to all other Group Health members, even those not in a Washington Dental Service plan. In the project s first sixteen months, 1,403 children (out of a total of 3,160 with well-child checks) received oral screening, fluoride varnish, and oral health education, representing 44 percent of all children with well-child visits. These early results indicate that oral health services have been well accepted by participating primary care teams. Building support among all members of the team led by a physician-champion is a critical predictor of successful adoption of this model. Developing efficient clinical workflows and tools for documentation and coding are also essential for success. The demonstration project also will include discussions with other private dental insurance carriers to determine the feasibility of reimbursement. It is hoped that this WDSF/Group Health collaboration can serve as a national model for early childhood caries prevention in primary care. Results: Changing The Standard Of Care Since 2001 the WDSF has invested $1.6 million to engage primary care providers in oral health. Largely because of the WDSF s overall engagement with program partners and primary care providers since 2001 and the combination of efforts noted in this paper, the number of fluoride varnish applications in medical settings in Washington delivered to Medicaidenrolled children under age six increased from 145 in 2000 to 9,098 in 2007. 16 The new legislation will likely increase this number. Although the WDSF ultimately aims to reach all primary care providers in Washington State, more than 775 pediatricians and family physicians have been trained through the foundation s initiatives to address oral health. This represents 24 percent of the state s nearly 3,300 family physicians and pediatricians. 17 At least 270 institutions nationwide usethesmilesforlifecurriculum,andtwenty medical schools use it in their core curricula. 18 Lessons learned from these efforts, plus lessons from other programs, such as North HEALTH AFFAIRS ~ Volume 27, Number 6 1731
Carolina s Into the Mouths of Babes, will help reach the goal of delivering preventive oral health services during well-child visits and mayeventuallyleadtochangingthestandard of care throughout the United States. 19 Based on the outcomes of the WDSF s initiatives to engage primary care providers, it is clear that such providers are interested in oral health. A physician-champion is critical to gaining support from other clinicians and staff. With efficient office processes and procedures, appropriate educational materials and training, and adequate reimbursements, providers can and will include oral health in well-child checkups. Another key factor is that primary care providers need to be able to easily refer patients especially those in Medicaid for follow-up dental care. Integrating oral health into well-child visits is both logical and practical, although evidence ofitsimpactisstillneeded.itisanopportunity to provide prevention services that can result in a lifetime of improved oral health. The bottom line is that dental disease can and should be prevented for every child at every opportunity including at the medical office. Highlights of the Group Health Cooperative demonstration project were presented at the American Academy of Pediatrics Peds 21 Conference, 10 October 2008, in Boston, Massachusetts. The Washington Dental Service Foundation provides financial support to Group Health Cooperative for implementing the demonstration project described in this paper. The authors acknowledge the organizations and individuals that have contributed to the initiatives in Washington State that are mentioned in this paper. NOTES 1. U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General (Rockville, Md.: National Institute of Dental and Craniofacial Research, May 2000), 17. 2. Ibid, 2. 3. B.A. Dye et al., Trends in Oral Health Status: United States, 1988 1994 and 1999 2004, April 2007, http:// www.cdc.gov/nchs/data/series/sr_11/sr11_248.pdf (accessed 11 August 2008). 4. Washington State Department of Health, Washington State Smile Survey 2005 (Olympia: DOH, Office of Maternal and Child Health, 2006). 5. Ibid, 37. 6. Joel Berg, director of dentistry, Children s Hospital and Regional Medical Center, Seattle, Washington, personal communication, June 2008. 7. Washington State Health and Recovery Services Administration, Dental Services Utilization Data, Fiscal Years 1997 2007 (Olympia: Washington State HRSA, 2008). 8. G.J. Donahue et al., The ABCDs of Treating the Most Prevalent Childhood Disease, American Journal of Public Health 95, no. 8 (2005): 1322 1324. 9. M.F. Savage et al., Early Preventive Dental Visits: Effects on Subsequent Utilization and Costs, Pediatrics 114, no. 4 (2004): e418 e423. 10. K.M.Pierce,R.G.Rozier,andW.F.VannJr., Accuracy of Pediatric Primary Care Providers Screening and Referral for Early Childhood Caries, Pediatrics 109, no. 5 (2002): e82 e88. 11. A.B. Douglass et al., Smiles for Life: A National Oral Health Curriculum for Family Medicine A Model for Curriculum Development for STFM Groups, Family Medicine 39, no. 2 (2007): 88 90. 12. Washington State HRSA, Dental Services. 13. Ibid. 14. Ibid. 15. Washington State HRSA, Memorandum no. 08-03, 21 February 2008, https://fortress.wa.gov/ dshs/maa/download/memos/2008memos/08-03%20dental_physreimb.pdf (accessed 30 June 2008). 16. Ibid. 17. Center for Health Workforce Studies, WWAMI Physician Workforce 2005 (Seattle: University of Washington, School of Medicine, Department of Family Medicine), 4. 18. Douglass et al., Smiles for Life. 19. G.G.delaCruz,R.G.Rozier,andG.Slade, DentalScreeningandReferralofYoungChildrenby Pediatric Primary Care Providers, Pediatrics 114, no. 5 (2004): e642 e652. 1732 November/December 2008