Category Archives: Access and barriers to care
Tiffany D. Joseph, PhD, is a Robert Wood Johnson Foundation (RWJF) Scholar in Health Policy Research at Harvard University (2011-2013). This post is part of a series in which RWJF scholars, fellows and alumni who are attending the American Public Health Association annual meeting reflect on the experience.
It was incredibly exciting to attend the American Public Health Association (APHA) meeting for the first time! As a sociologist and current RWJF Health Policy Research Scholar, I am thrilled to be at a multidisciplinary conference with an explicit focus on all aspects of health: outcomes, disparities, coverage, service utilization. You name it, there is a session for it.
The opening was especially motivating and inspiring as Dr. Reed Tuckson and Gail Sheehy provided insightful talks on the relevance of preventive health throughout the life course and how public health professionals must continue to work to improve access to, and quality of, health care for a U.S. population that is increasingly racially, ethnically, and socioeconomically diverse.
U.S. Representative Nancy Pelosi also stopped by, unannounced, to welcome the APHA to San Francisco and thank its members for their steadfast commitment to, and support for, passage and implementation of the Patient Protection and Affordable Care Act (PPACA or ACA). Needless to say, everyone in attendance was thrilled and excited by her surprise visit and warm words.
In the next one to three years, more than half of the nation’s physicians plan to retire, cut back on the number of patients they see, work reduced hours or take other steps that would reduce patient access to care, a survey from The Physicians Foundation finds. According to A Survey of America’s Physicians, which polled more than 13,000 physicians, a continuation of this trend could mean the loss of 44,250 physicians from the workforce in the next four years.
The survey finds that physicians are seeing fewer patients per day than they did in 2008, and 26 percent of physicians have closed their practices to Medicaid patients. Fifty-two percent have already or are planning to limit Medicare patient access to their practices.
More than three-quarters (77.4 percent) of the physicians surveyed are somewhat or very pessimistic about the future of the medical profession, and more than 84 percent agree that “the medical profession is in decline.” However, younger physicians, female physicians, employed physicians (as compared to those who own practices) and primary care physicians are generally more positive about their profession.
“The survey was conducted in the context of one of the most transformative eras in the history of modern healthcare,” the introduction to the study notes. “Physicians are at the vortex of these changes… It is a challenging and uncertain time to be a doctor. The results of the survey reflect this uncertainty and should be taken in the context of current events. As the course of healthcare reform becomes clearer, attitudes and perspectives may change. However, we believe the survey reveals what doctors are thinking today and is relevant to healthcare professionals, policy makers, media members, and to anyone who has been seen by a physician or who will be.”
Former Health & Human Services Secretary Louis Sullivan, MD, penned an op-ed in yesterday’s New York Times making the case for devising more effective ways to deliver dental care to poor or rural communities across the nation.
The Secretary notes that, in 2009, 83,000 emergency room visits resulted from preventable dental problems. “In my state of Georgia,” he writes, “visits to the ER for oral health problems cost more than $23 million in 2007. According to more recent data from Florida, the bill exceeded $88 million. And dental disease is the No. 1 chronic childhood disease, sending more children in search of medical treatment than asthma. In a nation obsessed with high-tech medicine, people are not getting preventive care for something as simple as tooth decay.”
He goes on to list several reasons: 50 million of us live in poor or rural areas without a dentist; most dentists do not accept Medicaid; and we have a dentist shortage that will only be exacerbated when 5.3 million children are added to Medicaid and the Children’s Health Insurance Program by way of the Affordable Care Act.
Sullivan argues that the federal government should put programs in place to train more dentists. But more than that, he argues for training dental therapists “who can provide preventive care and routine procedures like sealants, fillings and simple extractions outside the confines of a traditional dentist’s office.” He says such an approach has been particularly effective in Alaska, where the state has recruited and trained dental therapists to serve many of that state’s most remote communities, including many that are accessible only by plane, dogsled or snowmobile.
A recently announced effort by the Robert Wood Johnson Foundation (RWJF) takes aim at the very same problem. The Oral Health Workforce initiative is designed to improve access to oral health care by identifying and studying replicable models that make the best use of the health and health care workforce to provide preventive oral health services.
By David Krol, MD, MPH, FAAP, Robert Wood Johnson Foundation Human Capital Portfolio Team Director and Senior Program Officer
For many Americans, a visit to the dentist is a rarity—not by choice, but because their health plans don’t cover dental care, they can’t afford it, or because there is no dentist anywhere near where they live or work. If you’re on Medicare, you know that dental isn’t covered. If you’re part of the VA system, you know that dental benefits are treated differently. If you’re an adult on Medicaid or serve adult patients who are on Medicaid, you know the chances are slim that there’s great coverage for dental care, unless you are lucky to be in a state that still covers it. Why does this happen and what can result?
A study recently released by the Pew Center on the States offers startling data on the scope of the problem and its consequences. In 2009, some 830,000 Americans visited an emergency department for a preventable dental condition. It should be obvious that the emergency department isn’t the best place to seek dental care. The same year, 56 percent of Medicaid-enrolled children got no dental care whatsoever, not even a routine exam. That’s no care even with insurance for it!
Those numbers are alarming for many reasons, but mostly because they reveal a significant public health challenge confronting the nation: Many Americans simply aren’t getting the oral care they need, at any age, including the basic preventive services and education that can detect oral disease in early stages. They are putting their health at risk, and increasing the strain on an already-overwhelmed health care system.
February is National Children’s Dental Health Month, so the Human Capital Blog reached out to John Gusha, DMD, PC, a 2003 Robert Wood Johnson Foundation (RWJF) Community Health Leader, to learn more about children’s oral health. As project director of the Central Massachusetts Oral Health Initiative, Gusha mobilized dozens of dental societies and non-profit groups to provide dental care for low-income residents of Worcester County. Although funding for the Oral Health Initiative has ended, many of the programs Gusha helped create are still in place.
Human Capital Blog: What spurred the Central Massachusetts Oral Health Initiative? What made you aware of this need for oral health care in your community?
John Gusha: There was a special legislative report in 2000 that described disparities in access to oral health care for low-income populations. It raised a lot of questions about what we could be doing in the community and in the dental society to address these gaps. We got funding from the Health Foundation of Central Massachusetts, which also saw this as a critical need for our area, to launch the initiative.
HCB: Tell us about the school-based programs you put in place.
Gusha: The decay rate in Worcester County schools was very high—more than one-third of the students had active decay in their mouths. It was especially prominent in schools with high numbers of free and reduced price lunches, where students came from low-income families that are more likely to be using Medicaid. These students didn’t have access to care and weren’t getting the preventive services they needed.
We started a school-based program that is now in place in more than 30 Worcester County schools. Dental hygiene students from a local community college provide fluoride varnishes, cleanings and other preventive services to students, and the University of Massachusetts’ Ronald McDonald “Care Mobile” visits schools to offer the same services. Community health centers also participate in these programs by adding dental to their school-based health centers. In the past you could go to schools and provide services, but Medicaid rules didn’t allow you to get reimbursed. We were able to help get those rules changed so the program could become sustainable.
HCB: You also had a role in creating a dental residency program and training primary care providers to screen for oral health needs.
Gusha: We wanted to better integrate dentistry into medicine. The University of Massachusetts was the administrator of our program, and the team there developed a dental residency program at the medical school. The University had no classes in oral health before this. The local hospitals were in desperate need of professionals with this kind of training, particularly in emergency rooms. The Medicaid population was presenting there frequently for treatment because they had nowhere else to go, and people with other issues like cardiac problems or cancer needed clearance on their oral health in order to proceed with treatment.
The residency program is still in place at our two local community health centers, and it’s grown now to include education for other disciplines.
In many communities it is challenging to provide care for patients without insurance or with Medicaid, especially if they have complex or urgent health care needs. Getting approval for a diagnostic test or a timely appointment with a specialist - if it’s to happen at all - often requires several phone calls to empathic colleagues, cashing in on favors, and extensive coordination to make it all happen.
With a small pool of specialty physicians providing care for uninsured and underinsured adults, there is a limited capacity to provide timely care. Wait-times for appointments are long, and this often results in fragmented care plans, disease advancement and overuse of emergency departments and hospitals.
The supply-demand mismatch may get worse as strapped states cut Medicaid reimbursement levels to physicians and as the Patient Protection and Affordable Care Act takes effect, expanding Medicaid eligibility to an additional 15 million adults. In a recent New York Times guest editorial, Killing Medicaid the California Way, Bruce C. Vladeck, PhD, former assistant vice president of the Robert Wood Johnson Foundation (RWJF) and administrator of Medicare and Medicaid from 1993 to 1997, and Stephen I. Vladeck, JD, a professor of law at American University, give a grim account of the legal and political forces that may perpetuate provider shortages and ultimately threaten the equal access mandate.
But the problem of limited access for the uninsured and underinsured may not be so bleak. In 2008, six RWJF Scholars from Yale University (Erica S. Spatz, MD, MHS; Michael S. Phipps, MD, MHS; Katherine Goodrich, MD, MHS; Danil V. Makarov, MD, MHS; Kate V. Viola, MD, MHS; and Oliver J. Wang, MD, MBA, MHS) joined a local effort to bring a program called Project Access to New Haven, CT. Project Access expands the pool of providers for the uninsured by encouraging local specialty physicians and area hospitals to donate care; Project Access employs patients navigators to coordinate care and to address patient-level barriers to care delivery.
In a new study, RWJF Clinical Scholar Jeffrey T. Kullgren, M.D., M.S., M.P.H., and colleagues find that more U.S. adults postpone or go without medical care for nonfinancial reasons than for financial reasons. These barriers, such as inability to find a primary care physician, or limited office hours, are common and limit patient access to health care.
Read the story on the Human Capital Web site, and tell us what you think by taking the poll below.
By David Krol, M.D., M.P.H., F.A.A.P.
RWJF Human Capital Portfolio Team Director and Senior Program Officer
“Everyone has access to quality oral health care across the life cycle.”
That was the vision formed by a varied group of individuals from dentistry, dental hygiene, medicine, public health, nursing, economics, law, social work and philanthropy as they wrote the second of the Institute of Medicine’s reports on oral health, “Improving Access to Oral Health Care for Vulnerable and Underserved Populations.” I had the privilege of being a member of that committee. Our report was released on July 13th, 2011.
Our task was an expansive one. We were asked to:
- Assess the current U.S. oral health system of care;
- Explore its strengths, weaknesses and future challenges for the delivery of oral health care to vulnerable and underserved populations;
- Describe a desired vision for how oral health care for these populations should be addressed by public and private providers (including innovative programs) with a focus on safety net programs serving populations across the lifecycle and Maternal and Child Health Bureau programs serving vulnerable women and children; and
- Recommend strategies to achieve that vision.
Piece of cake right?!
Well, as you might guess, we found numerous, persistent and systemic barriers and challenges that vulnerable and underserved populations face in accessing oral health care. Those barriers include social, cultural, economic, structural, and geographic factors. We also recognized that these barriers contribute to profound and enduring oral health disparities in the United States. Americans who are poor, minority, or have special health care needs suffer disproportionately from dental disease and receive less care than the general population. It’s a sobering reality in that many of us take oral health care for granted or don’t even think about it at all until we are forced to.
On July 13, the Institute of Medicine released reports calling for expanded access to oral health care. In this post, Paul Glassman, D.D.S., M.A., M.B.A., a professor of dental practice and director of community oral health at the University of the Pacific, Arthur A. Dugoni School of Dentistry, discusses innovative models for improving the oral health of vulnerable and underserved populations. See all the posts in this series.
With the release of the Institute of Medicine (IOM) report on Improving Access to Oral Health Care for Vulnerable and Underserved Populations oral health is again highlighted on the national stage. This report, together with the IOM’s report on Advancing Oral Health in America released earlier this year, represent landmark calls to action on improving the oral health of the nation. I was privileged to serve on the IOM Committee on Oral Health Access to Services that produced the “Improving Access” report.
In a time when resources are dwindling, and public programs are being reduced, I find hope and opportunity for the future of oral health care for vulnerable and underserved populations. Generally in times when things are going well, people become complacent with the status quo and policy-makers are reluctant to contemplate big changes. Now, however, there is strong desire to find innovative solutions that will improve quality and lower costs.
At the highest level, the Affordable Care Act established the Center for Medicare and Medicaid Innovations (CMMI) at the Centers for Medicare and Medicaid Services (CMS). The new Center has $10 billion to “test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care for those who get Medicare, Medicaid or CHIP (Children’s Health Insurance Program) benefits.” Oral health advocates inside and outside CMS are urging the Center to include oral health innovations in its portfolio of activities.
The IOM reports also urge expanding use of previously tested models and further testing of innovative models for improving oral health of vulnerable and underserved populations. There are a number of models that have been developed that can potentially help more people get better oral health at lower cost. In this blog posting, I’ll briefly describe several I am familiar with although there are many others that are ongoing as well.
On July 13, the Institute of Medicine released reports calling for expanded access to oral health care. Esther Lopez, D.D.S., a graduate of the Robert Wood Johnson Foundation (RWJF) Dental Pipeline program, gave the following interview to the Human Capital Blog on the reports, as part of our ongoing Voices from the Field series. Lopez is a volunteer dentist and member of the Dental Advisory Committee at Goldie’s Place, a support center for the homeless in Chicago which houses a dental clinic. See all the posts in this series.
Human Capital Blog: The IOM report recommends the integration of oral health care into overall health care by training non-dental health care professionals to screen for oral disease and administer preventive care. What do you think of this approach to reaching underserved populations?
Esther Lopez: I definitely agree with this, mostly for the obvious reason that people who are losing out in dental health care are children and the elderly. Those two populations are the ones that visit primary providers the most – for a simple cold, the flu, a slip and fall accident – so having exposure to primary providers and non-dental health care professionals would be easier and more accessible. In order for this to happen we have to have more training available for these non-dental professionals. I see a lot of patients who come to Goldie’s Place with dental abscesses and things that need to be drained, that could be drained at a hospital. They go to a hospital are told that nothing can be done for them.