While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Position: Vice President and Director of Community Dentistry
Apple Tree Dental
When I saw Dr. Ebert, and he brought all his nice, clean equipment into the nursing home, it was heaven! He had to fix one of my upper front teeth that broke off. Dr. Ebert worked so hard for over an hour to fix that tooth so it wouldn't have to be pulled. It was beautiful, but after he was done, I could tell that he was in physical turmoil with a sore back. I know that some of his other patients make his job very hard. Some are demented, and can turn on you in a second. He sees very sick people whom, I'm sure, are very risky to treat. He inspires me with his kindness.—Patient
Above all, Dr. Ebert speaks and lives what he believes. At their very best, the helping professions place patient needs above personal needs. Dr. Ebert embodies this precept in his professional life.—Anthony DiAngelis, DDS, Chief of Medicine (Dentistry), Hennepin County (Minneapolis) Medical Center
While in dental school at the University of Minnesota, Carl Ebert was startled by the tremendous dental problems suffered by the elderly patients he was seeing in his clinical courses. The difficulty of travel and minimal medical assistance reimbursements prevented many from gaining access to dental care from traditional sources. The few residents who could both travel and afford to pay private fees often faced dentists who lacked experience with the dental needs of elderly patients. These barriers resulted in large unmet needs for dental care for the elderly, especially those in nursing homes. In fact, there was only one full-time dentist for the 8,000+ nursing home residents in the Twin Cities area. Dr. Ebert decided he would devote his career to improving access to dental care for these patients. He had known even before applying to dental school that he didn't want to spend his life practicing 9 to 5 in an office on "normal patients." But as graduation loomed, he had no idea how he was going to proceed with his ambitions.
His first job opportunity, in 1987, was with a "for-profit" practice that brought dental care to nursing home residents. The experience was not a happy one. Dr. Ebert perceived that he was working for a "Medicaid mill," and after two years, he quit to return to school for post-doctoral studies in geriatric dentistry. Here, too, though, he found his ambitions frustrated. "There wasn't a lot of money out there for developing access programs for the institutionalized elderly," he remembers. "Especially not in the academic world. There was only so much you could do." Nevertheless, he became even more inspired through his studies in public health and public policy to find a better way of serving vulnerable patients.
In 1991, Dr. Ebert finally found a way to bring his dreams to fruition, when he discovered an organization that could provide him with enthusiastic support—Apple Tree Dental of Minneapolis. Apple Tree was a different kind of dental program altogether. It was run through a nonprofit structure, and it served patients who were primarily disadvantaged—80 percent were on Medicaid, with reimbursements that were only half of average dental fees. The average age of the program's patients was 83. Many suffered from dementia, and other debilitating conditions that made it nearly impossible for them to travel to a dentist's office, and difficult to administer care to under most conditions. Apple Tree, while maintaining a clinic of its own, also brought portable care into the nursing homes, serving patients who otherwise would have had to go without care. Its dentists could set up this portable equipment, transported in a van, into a complete dental office in just 30 minutes. With its delivery systems, Apple Tree was able to provide check-ups, x-rays, cleanings, fillings, crowns and bridges, oral surgery, partial dentures, and full dentures—even to people confined to beds or wheelchairs. Though only a small operation, its patients represented 40 percent of nursing home residents in the Twin Cities.
Hired as Apple Tree's assistant director, Dr. Ebert began seeing patients full-time, at the same time refining the company's operations. He also helped to obtain funding from foundations and corporations for Apple Tree's care delivery.
In 1991, when Dr. Ebert came on board, Apple Tree was under severe financial pressure due primarily to under-reimbursement from Medicaid. This might have dictated a focus on clinical production, as had been the case with Dr. Ebert's former for-profit employers. But Dr. Ebert perceived a critical lack of advocacy in the dental community. "I realized that older folks were coming to the nursing home with years and years of neglect," he recalls. "As we get older, our dental care needs don't diminish, they go up in intensity of need. It told me that there's something wrong in our system. So that's what really got me going on the policy level." He soon persuaded Michael Helgeson, DDS, Apple Tree's director, that to provide dental benefits to the elderly, and for Apple Tree Dental's survival, state-level policy reform had to take place—and that strong leadership in public policy would be essential in this effort. Dr. Helgeson allowed Dr. Ebert to reduce his patient load to four days per week, and devote the other day, without pay, to advocacy.
Helgeson's decision to stretch limited resources to follow Dr. Ebert's vision was difficult, but crucial. It propelled Dr. Ebert himself into a leadership role as an outspoken advocate for the underserved—and eventually led to widespread recognition of the needs of, and support for, Apple Tree's patients among all the major health care policy developers in Minnesota. In his new role, Dr. Ebert created fruitful relationships, networks, and collaborations with governmental agencies, health care plans, professional organizations, advocacy groups, and leaders in the field of geriatrics. When, in 1993, he perceived the need to better coordinate the efforts of these interested parties, he co-founded the Minnesota Coalition for Oral Health for the express purpose of insuring adequate access to oral health services for the working poor, and to guarantee the inclusion of such services in health care reform initiatives. He worked on other coalitions as well, including the Health Care Services Delivery for Persons with Disabilities Stakeholders Group, and served on several committees sponsored by the Minnesota Department of Health, including its Ad Hoc Dental Public Health Committee, Medicaid Citizen's Advisory Committee, and its Dental Task Force.
His new role as an outspoken advocate often placed Dr. Ebert at direct odds with the policy positions of organized dentistry in Minnesota. "It's very hard for people in our profession to understand the whole notion of not-for-profit practice, and the profession doesn't have a great history of advocating for the underserved," he says with wry understatement. "Dentists don't believe in government programs. The only one they've been involved in is Medicaid." It was in large part due to Dr. Ebert's committee leadership at the state level that dental care was included in the MinnesotaCare Program, Minnesota's program for the working poor, as passed by the State Legislature in 1995.
During this period, Apple Tree Dental seized an opportunity to greatly expand its reach, by entering a partnership with a major dental insurance company to bring its style of dental care to rural residents in northwestern Minnesota. The State of Minnesota was about to offer a huge contract called APEX (Alliance of Purchasing Excellence), bringing together public employees and public program recipients into one large dental care contract covering 770,000 individuals. Believing this effort would serve as a vehicle for replication for its unique form of care, Apple Tree committed itself to a partnership with the large dental insurance company and began investing in infrastructure, working to open a satellite clinic. But almost a year after the state decided not to go forward with APEX, the insurance company backed out of the partnership, leaving Apple Tree stranded, and financially in peril.
At just this time, Dr. Ebert was honored as one of the recipients of the Robert Wood Johnson Community Health Leadership Award for 1997. With the award came a stipend of $100,000. The money could not have come at a better time for Apple Tree Dental. Dr. Ebert used the $100,000 to keep the satellite clinic open, while Apple Tree initiated an emergency fund-raising campaign. "We went to the community, and the foundations, and the corporations in the community," Dr. Ebert remembers, "and we raised enough money to get us over the hump of imminent disaster."
The financial cloud actually turned out to have a huge silver lining. As Dr. Ebert puts it, "Fighting for our survival drove us much, much closer to the community." To stabilize the dental access program in northwestern Minnesota, Dr. Ebert helped create a funding bill designed to leverage more dollars from the private sector through a state grant. The bill passed in the state legislature in 1999. Drawing on these funds, and on strong support from the community (leveraged private funds provided $9 for every state dollar), the satellite clinic survived and flourished—as did Apple Tree Dental. Community Health Leadership Program (CHLP) technical assistance funds, which were received after the award, provided Dr. Ebert with $4,500 to help pay for a professional fund-raiser—who has, to date, raised more than $600,000 for Apple Tree Dental. CHLP also provided for networking with other award winners, a process that Dr. Ebert has found very rewarding. "Just about every one of these award winners has run across some problem with dental care in their efforts," he says, noting that he is helping some of the other award winners with ideas to help them add dental care to their programs. In fact, Apple Tree is fast becoming a model for the nation. Replication efforts are underway in North Carolina, Ohio, Louisiana, and California. Apple Tree has no intention of franchising, however. "The solution," Dr. Ebert says, "is to have people who are very mission-oriented, and very committed, in every region, who can take a successful model and use it. We would never want to become the McDonald's of dentistry."
Apple Tree is currently expanding on its own turf in several ways: designing more advanced portable dental equipment, extending care to disabled and AIDS patients, and expanding the organization's partnership with the University of Minnesota's School of Dentistry so that dental students there can train at Apple Tree clinics. Apple Tree now employs 13 dentists, and its database tracks more than 10,000 patients.
Meanwhile, Dr. Ebert continues to educate community members and policymakers about the importance of oral health to every person, regardless of his or her age, special needs, or disability. He has emerged as a leading voice in dental public health in Minnesota, and his work with the legislature has helped bring dental treatment to more than 500,000 poor Minnesotans who wouldn't otherwise have dental care. His efforts in the policy arena have grown, over the years, to take up more and more of his time. At present, he spends three days per week in such activities (now on a salaried basis), but continues to see patients the other two days. He has clearly not forgotten them, nor will they ever forget him.
Of his vision, Dr. Ebert says, "Oral health is an essential element of overall health, and we need systems that foster innovation in health care. The old cottage industry model in dentistry isn't working for a lot of people. How do we do things to reach out to patients in non-traditional settings? How do we develop a financial environment that can support a growing organization like Apple Tree?"
To Dr. Carl Ebert, leadership means, "You can't be a quitter. I don't take no for an answer. And it really does come down to the issue of mission. You know, if you don't have that sense of mission, you're not going to get far in this realm." He believes there are a lot of people out there who could become leaders if they had more visible models to take after. "I hope," he says, "that leadership through example will be my biggest contribution."
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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