Cost of Delay: Four Effective State Strategies

Sealants

Studies have shown that sealant programs targeted to schools with many high-risk children are a highly recommended cost-effective strategy for providing sealants to children who need them. Sealants are one-third of the cost of fillings, and they can be applied by a less expensive workforce. But not all states have kept pace with current clinical and scientific recommendations. While dental hygienists in all states can apply sealants, some states require an examination by a dentist, or the physical presence of a dentist.

Most sealant programs identify target schools by the percentage of students who are eligible for free or reduced-cost lunch; other programs rely on parent surveys. Both approaches recognize that children living in poverty suffer two times more untreated tooth decay than their peers

State examples:

• In Ohio—a state whose school-based sealant programs have been lauded by the Centers for Disease Control for eliminating income disparity in sealants—the strategy is to reach out to all children in second and sixth grades in schools where at least 40 percent of the student body is enrolled in the free and reduced-cost lunch program.
  
  
• New Mexico’s Office of Oral Health has been sending dentists, hygienists and dental assistants to schools with high proportions of at-risk children to provide oral hygiene education, screening and sealants since 1979. For areas beyond its reach the office contracts with other providers.

Fluoridation

Water fluoridation policy is set at both state and local levels. While fluoridation decisions are frequently made by a health board or water utility, state legislatures and agencies can provide leadership and assistance. Currently, 12 states and the District of Columbia have mandatory fluoridation laws. On average, residents in states with fluoridation laws have more access to fluoridated water than residents in states with no such laws.

State example:

As of 2006, 78 percent of Texans had access to publicly fluoridated water, surpassing the national goal of 75 percent. The Texas Fluoridation Program awards start-up grants to local communities, provides engineering services and maintains data records to support their water fluoridation efforts. In communities with fluoridated water, tooth decay has decreased, while rates of decay have risen among children in communities without fluoridation. But the state’s success in fluoridating its communities’ water did not come without difficulty. Faced with vocal opposition from a few local groups, the Texas legislature commissioned a report from the state’s oral health program to investigate the safety and economic viability of water fluoridation. The report confirmed the proven health benefits gained from drinking water with optimal levels of fluoridation. Experts also determined a savings of $24 per child in Medicaid expenditures for children because of the cavities that were averted by drinking fluoridated water.

Medicaid

Federal law requires all states to provide medically necessary dental services for Medicaid-enrolled children. But nationwide, only 38.1 percent of such children ages one to 18 received any dental care in 2007. In part, this is because not enough dentists are willing to treat Medicaid-enrolled patients. Dentists point to low reimbursement rates, administrative hassles and frequent no-shows by patients as deterrents to serving them. Because of high overhead costs, dentists need to be compensated through Medicaid at a rate of at least 60 percent of their usual fees to break even.

Pew’s analysis found that Medicaid reimburses dentists at a national average of 60.5 percent of their usual fees, with 26 states falling below this level. But raising rates alone often is not enough—streamlining the administrative burdens for participating dentists and working collaboratively with providers are also important.

State examples:

Tennessee and Alabama both streamlined the administrative processes for their Medicaid dental programs. Tennessee bid out a contract to a specialized vendor and Alabama obtained a grant to revamp its own internal processes—and raised rates to levels close to dentists’ retail fees. In both states, the number of children receiving dental services more than doubled over just four years.

In Virginia, prior to reforms implemented in 2005, dentists were paid less than half of what it cost them to provide care. Consequently, only about 620 dentists statewide had been seeking reimbursement for treating Medicaid patients.Some dentists were seeing Medicaid patients for free so that they could sidestep the onerous paperwork involved. The state overhauled its Medicaid system—scrapping eight individual managed care organizations in favor of one private operator—and raised reimbursement rates by 30 percent. The number of participating dentists has more than doubled to 1,264 as of September 2009, and 94 percent of providers indicated in a recent survey that they are satisfied with the program.

Workforce Models

Communities that have a dearth of dentists available—such as rural and low-income urban communities—have little chance of attracting enough new dentists to meet the need. A growing number of states are exploring ways to expand the types of skilled professionals who can provide high-quality dental health care to disadvantaged children and their communitis. The types fall into three main baskets: medical providers; dental hygienists, and new types of dental professionals. These providers could expand access to basic care and refer more complex cases to dentists who may provide supervision on- or offsite.

State examples:

• A pioneering project in North Carolina enlists pediatricians and other medical providers to offer dental care to infants and toddlers. Preliminary results from a forthcoming evaluation show that children who participated in the program had a 40 percent reduction in cavities compared to those who did not.
  
  
• A Dental Health Aide Therapist program was launched in Alaska in 2003 under the authority of the Alaska Native Tribal Health Consortium to serve residents of remote Native Alaskan villages that typically rely on outside dentists to serve their communities once or twice a year. Today, there are dental therapists practicing in 11 villages. The therapists provide basic restorative and preventive services in satellite clinics in far-flung communities under the supervision of dentists at a hub clinic.
  
  
• In 2009, Minnesota became the first state in the country to authorize a new primary care dental provider.

Learn more about expanding the dental workforce.

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