Rebecca King, DDS, MPH NC State Dental Director Section Chief, Oral Health Section Rebecca.King@dhhs.nc.gov 1 Most common chronic disease of childhood Almost entirely preventable 30% of all health care costs for children Widespread disparities from lack of prevention and treatment, poor diet, access to care, insurance coverage, financial resources 2 1
Leads to Chronic i pain and medical complications i Early tooth loss, impaired speech development Poor nutrition, failure to thrive/impaired growth Inability to concentrate, lost school/work time Reduced self-esteem 3 Prevention that decreases costs is costsaving. Cost of prevention services plus treatment services < Cost of treatment services alone If benefits are large compared to costs, prevention is cost-effective - even if it doesn t save money. 4 2
In medicine, we put a cost on lives lost. For dental issues, do not currently quantify: time lost from work or school inability to sleep at night difficulty eating fewer trips to the dentist fewer fillings/restoration ti self consciousness clear speech quality of life 5 6 3
All water contains fluoride Fluoridation: adjusting the amount of fluoride to the optimal level for preventing decay Classic population-based strategy Focuses on environmental and policy changes, rather than behavioral changes Reaches large populations at low cost 7 CDC: For most cities, every $1 invested in fluoridation saves $38 in dental treatment costs.* Scientists testified before Congress in 1995 that national savings from water fluoridation estimated at $3.84 billion each year.** Texas 2000: the state saved $24/child/year in Medicaid expenditures for children because of the cavities prevented by drinking fluoridated water.*** (study required by Legislature) http://www.cdc.gov/fluoridation/fact_sheets/cost.htm* http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1459459/** www.dshs.state.tx.us/dental/pdf/fluoridation.pdf *** 8 4
New York 2010: treatment costs/medicaid recipient were $23.65 higher h for those living i in less fluoridated d counties* Colorado 2003: Saved ~$149 million in unnecessary treatment costs by fluoridating Average savings of ~ $61/person.** * Public Health Reports (November-December 2010), Vol. 125, 788. ** http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1459459/ 9 One of the few public health measures that results in true cost savings 10 5
Jay Kumar, DDS, MPH 11 Build support - internal & external Engage partners and stakeholders State Oral Health Coalition Rural Water Association Local Health Departments State Dental Association Develop resources Provide training Advocate for investment 12 6
Document savings in New York State Advocate for investing in cost savings intervention Develop a method for supporting costs of fluoridation equipment, supplies and staff time 13 Evaluation to determine if # claims for cavity-related Medicaid id procedures varied by fluoridation i coverage Used 2006 Medicaid claims data Finding: # of cavity-related procedures (e.g. fillings, extractions) 33.4% higher in less fluoridated areas. Promotes policies to strengthen fluoridation Kumar, Adekugbe, Melnik. Public Health Reports, September October 2012 Vol 25 14 7
13) Medicaid Coverage of Water Fluoridation: To address disparities in access to dental services the Workgroup recommends that Medicaid funding be made available to support costs of fluoridation equipment, supplies and staff time for public water systems in population centers (population over 50,000) where the majority of Medicaid eligible children reside. http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrtcompani on.pdf 15 On the allowability of Medicaid financing for fluoridation as a strategy to reduce oral disease burden while lowering aggregate Medicaid dental expenditures. CMS has recently provided guidance to states regarding Medicaid financing of tobacco cessation quit lines. Medicaid supports administrative activities through the Medicaid Administrative Claiming process. 16 8
17 Clear plastic coatings painted on the chewing surfaces of teeth Can be provided in dental offices or in schoolbased clinics Cost can depend on where provided Effectiveness depends on risk status of patient selection Cost effective, sometimes cost savings 18 9
North Carolina s Statewide Medicaid Dental Prevention Program for Young Children 19 Growing concern over pediatric oral health States are experimenting with different models Physicians are being called on to provide dental services AAP policy statements (2003, 2008) Maternal and Child Health Bright Futures guidelines, 3 rd ed. 2008 Pew and Kellogg Foundations National Interprofessional Initiative on Oral Health 20 10
Increase access to preventive dental care Reduce prevalence of Early Childhood Caries (ECC) Reduce the burden of treatment needs on the dental care system 21 Pilot volunteer trainer June 2000 funding from CMS to Medicaid agencies for innovative programs to reduce ECC Partners NC Medicaid NC Oral Health program UNC Schools of Public Health and Dentistry Community leaders NC Pediatric Society and Academy of Family Physicians Additional funding from Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC) 22 11
State Oral Health program provides training for medical providers Dedicated staff person central contact Medicaid reimburses for up to 6 visits before age 3 1/2 Oral evaluation and risk assessment Referral for dental care Fluoride varnish application Caregiver education University it of North Carolina Gillings School of Global Public Health does ongoing evaluation 23 No reduction in use of dental preventive services Statistically significant increase in use of treatment services and improved oral health Services in every county (formerly none in 1/3) At least 4 visits by age 4 Statistically significant reduction in need for treatment of front teeth * Research Brief, Evaluation of IMB Program, Rozier et. al. UNC CH School of Public Health, June 2007. 24 12
High adoption rates among medical providers 450 practices Increased access to preventive services Wide geographic distribution 43% of well-child visits Physician visits 4 times greater than dentists Multiple visits 20 times greater in medical offices Rozier et al. J Dent Educ 2003;67:876-85. Close et al. Pediatrics. 2008;122:1387-94. Rozier et al. Health Affairs. 2010;29:2278-85. 25 *For years 2000-2006 includes 1-2 yr olds only, for 2007 only includes 1-3 year olds. 26 13
Physicians identify disease or not with 93% accuracy Referral practices Overall rate = 2.8%; with tooth decay = 33% 3-fold increase in dental use (36% vs. 12%) When advised to see a dentist, kids are 2.9 X more likely to have a dental visit Pierce et al. Pediatrics. 2002;109:E82-2. Pahel et al. 2008. Beil & Rozier. Pediatrics. 2010;126:e435-41. 27 Reductions in treatment were substantial (49%) before 18 months of age From about 2 3½ years of age, net effectiveness was reduced Probably because of early detection / referral effect Overall, program was effective in reducing cavity-related treatments through 6 years of age Net reduction of 18% with >4 visits Pahel et al. Pediatrics. 2011:e682-9 28 14
Sample: ~25,000 children with 4 IMB visits Children had lower Medicaid dental payments from having fewer caries-related treatments and a lower probability of hospitalization. The IMB program is cost-effective with 95% certainty at a willingness to pay $170 to avoid a dental treatment and $2600 to avoid a hospitalization. * Stearns, Rozier, Kranz, Pahel, Quiñonez. Poster presentation, AADR Meeting, Tampa, Florida March 2012 29 At about $35 per IMB visit, in this study sample the IMB program would be cost-saving. Limitations: Results maybe affected by patient selection Only treatment can be measured, rather than dental health * Stearns, Rozier, Kranz, Pahel, Quiñonez. Poster presentation, AADR Meeting, Tampa, Florida March 2012 30 15
31 Involves complex physiological changes that can adversely affect oral health. Emerging evidence shows association between gum infection and adverse outcomes (e.g. premature delivery, low birth-weight) Ideal time to educate women about preventing cavities in young children 32 16
National Center for Education in Maternal and Child Health American Dental Association American Academy of Pediatric Dentistry American Academy of Periodontology America Academy of pediatrics NY State Department of Health 33 Convened expert panel Developed recommendations for oral health Evidence-based where possible Expert consensus where controlled studies weren't available Recommendations for health care professionals Prenatal Oral health Child health Goals Bring about changes in health care delivery system Improve overall standard of care 34 17
Dental care is safe and effective during pregnancy. Prenatal and oral health care providers need to coordinate. Improve women's health by good oral hygiene and nutrition. Get needed dental treatment before delivery Actions to reduce risk of cavities for children Proper oral hygiene Limit sugars Avoid sharing saliva/germs Visit dental professional between 6-12 months of age 35 Oral Health Care during Pregnancy and Early Childhood d (NY) http://www.vahealth.org/dental/documents/2008/pdfs/n ew%20york%20state%20oral%20health%20and%20pr egnancy%20guidelines.pdf Oral Health Care During Pregnancy: A Summary of Practice Guidelines http://www.healthplex.com/pdfs/oral%20health%20care %20During%20Pregnancy%20Guidelines%20for%20Prof essionals.pdf 36 18
Association of State and Territorial Dental Directors (ASTDD) http://www.astdd.org/state-programs/ http://www.astdd.org/best-practices/ ASTDD policy statements http://www.astdd.org/docs/water_fluoridation_policy_s tatement_april_18_2009_2010-10.pdf http://www.astdd.org/docs/fluoride_varnish_policy_stat p// / ement_april_25_2010_new_logo_2010-10.pdf http://www.astdd.org/docs/school-based_or_school- Linked_Mobile_or_Portable_Dental_Services_Policy_State ment_february_28_2012.pdf 37 Prevention is key! First priority is programs that are cost savings, but few procedures are cost savings Identify programs that are cost effective What price is society willing to pay? 38 19