AJPH PERSPECTIVES Improving Access to Oral Health Services Among Uninsured and Underserved Populations: FirstHealth Dental Care Centers See also Borrell, p. S6.
In 1998, as part of the W. K. Kellogg Foundation Community Voices Initiative, FirstHealth of the Carolinas, a regional health care network, took up the challenge of eliminating longstanding rural disparities in access to oral health services by opening the first of three pediatric dental care centers serving Hoke, Montgomery, and Moore counties in North Carolina. Since the opening of these dental public health practices in private settings, a plethora of factors have changed. Shifts in demographics and insured status, demand for services, and economic backing have all contributed to an altered landscape for the FirstHealth model. Ensuring access to oral health services is crucial in efforts to eliminate oral health disparities. However, from a business perspective, stand-alone dental care delivery models that focus primarily on safety-net populations may not be sustainable. Here we describe how FirstHealth has continued to address disparities in access to oral health services among rural low-income children while adjusting to the changing fiscal environment.
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DISPARITIES A local oral health task force in North Carolina identified oral health care as the primary unmet need among low-income children in the state’s Sandhills region. Inadequate access to oral health care results in preventable oral disease and conditions. In general, dental provider shortages in rural areas are well documented. In the case of low-income and minority populations, this issue is compounded by a lack of dentists who accept Medicaid and, with recent increases in racial/ethnic diversity, the need for more culturally and linguistically responsive care.1 In the late 1990s, private practice offices in the region were at capacity owing to the large number of retirees in the area and the fact that few dentists accepted Medicaid. Furthermore, there were only 47 practicing pediatric dentists in North Carolina.2 In the three counties of Hoke, Montgomery, and Moore, there were 12 000 medically underserved children without access to dental care. FirstHealth took the innovative step of building dental care centers under the auspices of a hospital system, and these centers provide comprehensive dental care to
underserved children up to the age of 21 years. The most significant racial/ ethnic demographic shift in Hoke, Montgomery, and Moore counties has been the increase in the Hispanic population (between 2000 and 2015, the Hispanic populations in these counties increased by 5.2%, 5.1%, and 2.4%, respectively). The FirstHealth clinic populations reflect the same shift observed in the general population. Over the past 12 years, the growth in Hispanic patients has outpaced that of all other racial groups. The percentage of Caucasians in the clinic populations has decreased from 38% to 21%, the percentage of African Americans has decreased from 42% to 34%, and the percentage of Hispanics has more than doubled, from 16% to 34%. FirstHealth’s response has been swift and deliberate, providing bilingual staff members in each
office and translating all clinic materials into Spanish. Although the technical aspects of interpretation and translation are paramount, even more important are the cultural sensitivity efforts made to meet the needs of the Spanish-speaking population and to increase dental health literacy. Results since the dental centers’ inception have been significant in terms of pediatric oral health status. The data in Table 1 show the percentage of kindergartners with decayed teeth in the 1997–1998 school year, before the centers opened, as compared with the latest data for children in the region.3
FINANCING In response to the evolving fiscal environment, FirstHealth has made explicit efforts to improve enrollment and retention of patients eligible for Medicaid or other public coverage. Also, it has sought supplemental financial support to offset “loss leader” services (e.g., a dental service for which reimbursement does not cover the expense of delivering the service). Medicaid is a crucial component in the financing and sustainability of the dental care centers. FirstHealth has made
ABOUT THE AUTHORS Sharon Nicholson Harrell is with FirstHealth of the Carolinas Dental Care Centers, Pinehurst, NC, and the Departments of Dental Ecology and Operative Dentistry, University of North Carolina School of Dentistry, Chapel Hill. Marguerite Ro is with Public Health-Seattle and King County, Seattle, WA. Lisa Gaarde Hartsock is with Treasure House, Phoenix, AZ. Correspondence should be sent to Sharon Nicholson Harrell, DDS, MPH, FAGD, FICD, FirstHealth Dental Care Centers, 105 Perry Dr, Southern Pines, NC 28387 (e-mail: sharrell@ firsthealth.org). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted March 5, 2017. doi: 10.2105/AJPH.2017.303773
AJPH
Supplement 1, 2017, Vol 107, No. S1
AJPH PERSPECTIVES
TABLE 1—Comparison of the Percentages of Kindergarten Children With Untreated Tooth Decay Before and After Introduction of FirstHealth Dental Care Centers: Three North Carolina Counties and the State as a Whole, 1997–1998 and 2013–2014 Children With Decayed Teeth, % Area
1997–1998
2013–2014
Hoke County
33
11
Montgomery County
38
21
Moore County
23
17a
State overall
23
13
Source. Data were derived from the North Carolina Department of Health and Human Services.3 a The latest data for Moore County are for 2009–2010.
concerted efforts to help the families and individuals eligible for the program apply for Medicaid or Health Choice (Children’s Health Insurance Program). The number of insured patients has increased dramatically since the centers opened, with an insured rate of 72% across the three centers in 1998 as compared with the current rate of 96%. Even with the increases in coverage, the dental care centers are at high risk for being loss leaders as a result of shifting Medicaid reimbursement rates. Over the past 12 years, there have been notable changes in Medicaid reimbursement. In 2000, plaintiffs (low-income Medicaid children in North Carolina) brought a lawsuit against the North Carolina Department of Health and Human Services challenging the adequacy of dental reimbursement rates and the state’s efforts to ensure access to dental care. As part of the settlement of the Antrican v. Bruton case in 2003, the Division of Medical Assistance increased the reimbursement rates for a selected list of dental procedures commonly provided to children.4 Although the increase in Medicaid reimbursement did not
Supplement 1, 2017, Vol 107, No. S1
influence the payor mix, the centers had a positive bottom line in the full year after the increase for the first time since their inception. In the following years, Medicaid reimbursement has fluctuated, with sharp decreases in the last seven years. Since 2009, although operating costs have stabilized as a result of streamlining, Medicaid reimbursements have decreased by 9.52%.5 Being part of a larger system has been critical to the sustainability of the dental care centers, as FirstHealth has financial mechanisms in place to offset loss leader services (albeit fewer such mechanisms than in the early 2000s owing to recent increases in charity care across the system as a whole). A “stand-alone” clinic would not be able to shift any debt at all. The Foundation of FirstHealth has also played a vital and significant role, first by supplementing capital support and second by providing an annual disbursement that serves as a buffer between Medicaid reimbursements and program operating expenses. The annual disbursement offsets almost 40% of the net income loss. In addition, the Foundation of FirstHealth has established a dental care endowment that will allow
AJPH
the centers to use interest to offset any additional losses when a target amount is reached. Financially maintaining an existing successful dental public health program becomes more difficult each year. To sustain the dental care centers, FirstHealth is exploring options that include diversifying the payor mix. Although commercial insurance is not broadly accepted, the clinics have opened the practices to the children of FirstHealth employees. The dental care centers’ service population remains 99% Medicaid, Health Choice, and uninsured, low-income self-pay, and thus the threat of patients losing services owing to their finances continues.
The dental care centers’ membership in a large health system has been a major component in ensuring their financial sustainability. FirstHealth has an undaunted commitment to improving the oral health of children and will continue to pilot, model, and seek strategies that lead to oral health equity regardless of place, income, or race/ ethnicity. Sharon Nicholson Harrell, DDS, MPH, FAGD, FICD Marguerite Ro, DrPH Lisa Gaarde Hartsock, MPH CONTRIBUTORS All of the authors contributed equally to this article.
REFERENCES
CONCLUSIONS With nearly two decades of delivering care, FirstHealth’s experiences can provide lessons for other communities addressing oral health needs. Most important, FirstHealth has demonstrated the role that a health care system can play in addressing oral health disparities. By adding pediatric dental care centers, FirstHealth has expanded access to oral health services among at-risk children, and it continues its efforts to ensure culturally and linguistically appropriate care for an increasingly diverse population. FirstHealth also demonstrates how a large health system can be part of the dental safety net and respond to an ever-evolving fiscal environment. Dental care staff continue to help many uninsured families enroll in Medicaid so that they can receive muchneeded care. In addition, FirstHealth continues to seek other sources of funding to address evolving changes in Medicaid reimbursement.
1. Bayne A, Knudson A, Garg A, Kassahun M. Promising practices to improve access to oral health care in rural communities. Available at: http://www.norc.org/ PDFs/Walsh%20Center/Oral_Rural% 20Evaluation%20Issue%20Brief-6pg_ mm.pdf. Accessed March 14, 2017. 2. North Carolina Institute of Medicine Task Force on Dental Care Access. Report to the North Carolina General Assembly and to the Secretary of the North Carolina Department of Health and Human Services. Morrisville, NC: North Carolina Institute of Medicine; 1999. 3. North Carolina Department of Health and Human Services. North Carolina oral health. Available at: https://www2. ncdhhs.gov/dph/oralhealth. Accessed March 14, 2017. 4. North Carolina Institute of Medicine Task Force on Dental Care Access. 2003 update: report to the North Carolina General Assembly and to the secretary of the North Carolina Department of Health and Human Services. Available at: http:// www.nciom.org/wp-content/uploads/ 2003/01/dentalupdate03.pdf. Accessed March 14, 2017. 5. Baker D. Documentation of Medicaid Rate Changes. Raleigh, NC: North Carolina Department of Health and Human Services; 2016.
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In 1998, as part of the W. K. Kellogg Foundation Community Voices Initiative, FirstHealth of the Carolinas, a regional health care network, took up the challenge of eliminating longstanding rural disparities in access to oral health services by opening the first of three pediatric dental care centers serving Hoke, Montgomery, and Moore counties in North Carolina. Since the opening of these dental public health practices in private settings, a plethora of factors have changed. Shifts in demographics and insured status, demand for services, and economic backing have all contributed to an altered landscape for the FirstHealth model. Ensuring access to oral health services is crucial in efforts to eliminate oral health disparities. However, from a business perspective, stand-alone dental care delivery models that focus primarily on safety-net populations may not be sustainable. Here we describe how FirstHealth has continued to address disparities in access to oral health services among rural low-income children while adjusting to the changing fiscal environment.
S48
Editorial
Harrell et al.
DISPARITIES A local oral health task force in North Carolina identified oral health care as the primary unmet need among low-income children in the state’s Sandhills region. Inadequate access to oral health care results in preventable oral disease and conditions. In general, dental provider shortages in rural areas are well documented. In the case of low-income and minority populations, this issue is compounded by a lack of dentists who accept Medicaid and, with recent increases in racial/ethnic diversity, the need for more culturally and linguistically responsive care.1 In the late 1990s, private practice offices in the region were at capacity owing to the large number of retirees in the area and the fact that few dentists accepted Medicaid. Furthermore, there were only 47 practicing pediatric dentists in North Carolina.2 In the three counties of Hoke, Montgomery, and Moore, there were 12 000 medically underserved children without access to dental care. FirstHealth took the innovative step of building dental care centers under the auspices of a hospital system, and these centers provide comprehensive dental care to
underserved children up to the age of 21 years. The most significant racial/ ethnic demographic shift in Hoke, Montgomery, and Moore counties has been the increase in the Hispanic population (between 2000 and 2015, the Hispanic populations in these counties increased by 5.2%, 5.1%, and 2.4%, respectively). The FirstHealth clinic populations reflect the same shift observed in the general population. Over the past 12 years, the growth in Hispanic patients has outpaced that of all other racial groups. The percentage of Caucasians in the clinic populations has decreased from 38% to 21%, the percentage of African Americans has decreased from 42% to 34%, and the percentage of Hispanics has more than doubled, from 16% to 34%. FirstHealth’s response has been swift and deliberate, providing bilingual staff members in each
office and translating all clinic materials into Spanish. Although the technical aspects of interpretation and translation are paramount, even more important are the cultural sensitivity efforts made to meet the needs of the Spanish-speaking population and to increase dental health literacy. Results since the dental centers’ inception have been significant in terms of pediatric oral health status. The data in Table 1 show the percentage of kindergartners with decayed teeth in the 1997–1998 school year, before the centers opened, as compared with the latest data for children in the region.3
FINANCING In response to the evolving fiscal environment, FirstHealth has made explicit efforts to improve enrollment and retention of patients eligible for Medicaid or other public coverage. Also, it has sought supplemental financial support to offset “loss leader” services (e.g., a dental service for which reimbursement does not cover the expense of delivering the service). Medicaid is a crucial component in the financing and sustainability of the dental care centers. FirstHealth has made
ABOUT THE AUTHORS Sharon Nicholson Harrell is with FirstHealth of the Carolinas Dental Care Centers, Pinehurst, NC, and the Departments of Dental Ecology and Operative Dentistry, University of North Carolina School of Dentistry, Chapel Hill. Marguerite Ro is with Public Health-Seattle and King County, Seattle, WA. Lisa Gaarde Hartsock is with Treasure House, Phoenix, AZ. Correspondence should be sent to Sharon Nicholson Harrell, DDS, MPH, FAGD, FICD, FirstHealth Dental Care Centers, 105 Perry Dr, Southern Pines, NC 28387 (e-mail: sharrell@ firsthealth.org). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted March 5, 2017. doi: 10.2105/AJPH.2017.303773
AJPH
Supplement 1, 2017, Vol 107, No. S1
AJPH PERSPECTIVES
TABLE 1—Comparison of the Percentages of Kindergarten Children With Untreated Tooth Decay Before and After Introduction of FirstHealth Dental Care Centers: Three North Carolina Counties and the State as a Whole, 1997–1998 and 2013–2014 Children With Decayed Teeth, % Area
1997–1998
2013–2014
Hoke County
33
11
Montgomery County
38
21
Moore County
23
17a
State overall
23
13
Source. Data were derived from the North Carolina Department of Health and Human Services.3 a The latest data for Moore County are for 2009–2010.
concerted efforts to help the families and individuals eligible for the program apply for Medicaid or Health Choice (Children’s Health Insurance Program). The number of insured patients has increased dramatically since the centers opened, with an insured rate of 72% across the three centers in 1998 as compared with the current rate of 96%. Even with the increases in coverage, the dental care centers are at high risk for being loss leaders as a result of shifting Medicaid reimbursement rates. Over the past 12 years, there have been notable changes in Medicaid reimbursement. In 2000, plaintiffs (low-income Medicaid children in North Carolina) brought a lawsuit against the North Carolina Department of Health and Human Services challenging the adequacy of dental reimbursement rates and the state’s efforts to ensure access to dental care. As part of the settlement of the Antrican v. Bruton case in 2003, the Division of Medical Assistance increased the reimbursement rates for a selected list of dental procedures commonly provided to children.4 Although the increase in Medicaid reimbursement did not
Supplement 1, 2017, Vol 107, No. S1
influence the payor mix, the centers had a positive bottom line in the full year after the increase for the first time since their inception. In the following years, Medicaid reimbursement has fluctuated, with sharp decreases in the last seven years. Since 2009, although operating costs have stabilized as a result of streamlining, Medicaid reimbursements have decreased by 9.52%.5 Being part of a larger system has been critical to the sustainability of the dental care centers, as FirstHealth has financial mechanisms in place to offset loss leader services (albeit fewer such mechanisms than in the early 2000s owing to recent increases in charity care across the system as a whole). A “stand-alone” clinic would not be able to shift any debt at all. The Foundation of FirstHealth has also played a vital and significant role, first by supplementing capital support and second by providing an annual disbursement that serves as a buffer between Medicaid reimbursements and program operating expenses. The annual disbursement offsets almost 40% of the net income loss. In addition, the Foundation of FirstHealth has established a dental care endowment that will allow
AJPH
the centers to use interest to offset any additional losses when a target amount is reached. Financially maintaining an existing successful dental public health program becomes more difficult each year. To sustain the dental care centers, FirstHealth is exploring options that include diversifying the payor mix. Although commercial insurance is not broadly accepted, the clinics have opened the practices to the children of FirstHealth employees. The dental care centers’ service population remains 99% Medicaid, Health Choice, and uninsured, low-income self-pay, and thus the threat of patients losing services owing to their finances continues.
The dental care centers’ membership in a large health system has been a major component in ensuring their financial sustainability. FirstHealth has an undaunted commitment to improving the oral health of children and will continue to pilot, model, and seek strategies that lead to oral health equity regardless of place, income, or race/ ethnicity. Sharon Nicholson Harrell, DDS, MPH, FAGD, FICD Marguerite Ro, DrPH Lisa Gaarde Hartsock, MPH CONTRIBUTORS All of the authors contributed equally to this article.
REFERENCES
CONCLUSIONS With nearly two decades of delivering care, FirstHealth’s experiences can provide lessons for other communities addressing oral health needs. Most important, FirstHealth has demonstrated the role that a health care system can play in addressing oral health disparities. By adding pediatric dental care centers, FirstHealth has expanded access to oral health services among at-risk children, and it continues its efforts to ensure culturally and linguistically appropriate care for an increasingly diverse population. FirstHealth also demonstrates how a large health system can be part of the dental safety net and respond to an ever-evolving fiscal environment. Dental care staff continue to help many uninsured families enroll in Medicaid so that they can receive muchneeded care. In addition, FirstHealth continues to seek other sources of funding to address evolving changes in Medicaid reimbursement.
1. Bayne A, Knudson A, Garg A, Kassahun M. Promising practices to improve access to oral health care in rural communities. Available at: http://www.norc.org/ PDFs/Walsh%20Center/Oral_Rural% 20Evaluation%20Issue%20Brief-6pg_ mm.pdf. Accessed March 14, 2017. 2. North Carolina Institute of Medicine Task Force on Dental Care Access. Report to the North Carolina General Assembly and to the Secretary of the North Carolina Department of Health and Human Services. Morrisville, NC: North Carolina Institute of Medicine; 1999. 3. North Carolina Department of Health and Human Services. North Carolina oral health. Available at: https://www2. ncdhhs.gov/dph/oralhealth. Accessed March 14, 2017. 4. North Carolina Institute of Medicine Task Force on Dental Care Access. 2003 update: report to the North Carolina General Assembly and to the secretary of the North Carolina Department of Health and Human Services. Available at: http:// www.nciom.org/wp-content/uploads/ 2003/01/dentalupdate03.pdf. Accessed March 14, 2017. 5. Baker D. Documentation of Medicaid Rate Changes. Raleigh, NC: North Carolina Department of Health and Human Services; 2016.
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