Boom Times for Dentists, but Not for Teeth New York Times October 11, 2007

 Health History and Oral Cancer Screening  Caries Check, Clinical and Radiographic  Periodontal Assessment Types of Dental Disease

 27% of Children have untreated disease  29% of Adults have untreated disease  Data higher than 1980 and significantly higher than 1999 Prevention Data from 2004

Factors Related to Disparities in Access to Oral Health Care Harvey Weingarten DDS University of Notre Dame February 2008

Many poor, lower income families don’t have any insurance, cash or governmental entitlement programs Access to care is an issue even with those who can afford dental treatment

In 1982 we had 5,750 graduates of dental school In the last fifteen years 7 dental schools have closed their doors In 2003 we had 4,400 graduates of dental schools

 Average age of Dentist is 49 years old  Beginning in 2012 more dentists will be retiring than graduating  States need to liberalize expanded auxiliaries laws

 DDS ◦ 3,213 practicing in Indiana ◦ Statewide Ratio 1:1,952 people  RDH ◦ 3,661 practicing in Indiana ◦ Statewide Ratio 1:1,713 people Total Dentists & Dental Hygienists to Population (8-06)

Retention of IUSD Grads: How many remain in Indiana? N=451 of 498 (91%) of IUSD grads from 1994 – 1999 (contacted in 2003) In State StudentsOut of State Students

Hamilton County1: 999 Marion County1:1,370 Boone County1:1,407 Floyd County1:1,469 Howard County1:1:1491 Range of Ratio of Dentists to Population by Indiana County 2006 (5 lowest and 5 highest) Warren County1: 8,785 Switzerland County 1: 9,718 Crawford County 1:11,216 Starke County1:11,467 Ripley County1:14,855

 Population 266,160  137 Dentists or 1 per 1,943  231 Hygienists or 1 per 1,152 Ratio of Dentists and Dental Hygienists in St Joe County

Indiana Population Trends

Ratio of Dental Hygienists to Indiana Population by Year (1:x) Sources: Indiana Professional Licensing Agency & US Census Bureau

Ratio of Dentists to Indiana Population by Year (1:x) Sources: Indiana Professional Licensing Agency & US Census Bureau

DHPSA designations enable $25K-35K annual tax free loan repayment plus salary – incentive for new graduates to practice in rural and inner city underserved areas More Counties qualify than are designated Ratio of 1 dentist per 5,000 or more people

Rural Status of Indiana  In 32 of 92 counties (35%) >75% of land is farmland  46 of 92 counties (50%) are officially  designated as rural  Nearly 2/3 of Indiana’s 23 million acres are farmlands ◦ 5/92 counties >90% farmland ◦ 6/92 counties <33% farmland

 11 of 92 counties do not have any Medicaid providers  52 CHCs with 25 Dental Clinics (13 are in Indianapolis) ◦ See attached table listing community health centers and dental clinics)  Distribution ◦ DDS with smallest patient pool are in affluent areas ◦ DDS with largest patient pool are in rural and impoverished inner-city areas Barriers to Locating a Dental Home in Rural Counties

 Limitations due to lack of current epidemiological data ◦ Last statewide survey  No data on the oral health of special population groups; adults; elderly; disabled  Marion County survey of children conducted in 2000 by IUSD for MCHD Measuring the Need

Drawing Some Data from SEAL INDIANA Records Services Provided March Dec 2006  10,938 children examined to date  16,928 sealants placed  7,831 Fluoride varnish  1,919 BW x-rays (6-14 yrs)  674 days at 575 sites in Indiana Children with untreated carious lesions: 52% 35% = non-urgent 17% = urgent All are children from low income families

Percentage with Caries History (HP2010 goal 42%)

Percentage with Untreated Carious Lesions by Severity

 Economic Issues  Number of Dentists / Ratio of Dentists to Population  Geographic distribution Factors Influencing Need and Demand for Care

 Unfunded  Unaccepted  Inaccessible  Unconvinced  Unmotivated  Powerless Other Factors Contributing to Underutilization of Dental Services

 6.2 million Hoosiers  From 2000 to 2004 Indiana lost 138,800 jobs  Change: manufacturing jobs, service sector and small business (less likely to provide dental insurance to employees)  Food Stamps and Temporary Assistance for Needy Families (TANF) have nearly doubled in 5 years  Highest per capita rate of medically bankrupt families (>77,000 Hoosiers) Economic Status of Indiana

 >30% of Hoosiers who are uninsured are employed by companies that offer coverage, but it’s not affordable, or they are not eligible (part time/seasonal)  Indiana health insurance rates have increased by double digit rates for the last four years, higher than the national average.  Many Hoosier small businesses have dropped health and dental insurance benefits Factors Contributing to Uninsured Status Source: Kaiser Family Foundation 2004

Medicaid/ Hoosier Healthwise $4.5 Billion annual budget Dental expenditures = 2.5% 21-30% of children enrolled received dental care in a given year Reimbursement rates are higher than the national norm 24% of Indiana children 0-18 are covered by Hoosier Healthwise

 24% children 0-18 years (nat’l 26%)  9% women (nat’l 9%)  4% men (nat’l 6%) Indiana Medicaid/Hoosier Healthwise Coverage

 Undocumented Immigrant Children: eligible only for Pkg E Medicaid (E=Emergency only – no dental care unless life threatening)  Indiana Population  6,271,973 Indiana population July 2005  Estimated 4.4% are Hispanic = 275,966  160,000 Hispanic citizens  65,000 Undocumented immigrants*  Other estimates 50,000 – 10,000 Barriers to Medicaid Enrollment * Pew Hispanic Center 2004

 91% of children <poverty level  39% Hispanic  30% enrolled in Hoosier Healthwise vs 55% in other schools  29% had severe caries vs 17% in other schools Case Study: Kyger School – Frankfort, Indiana Clinton County - Designated Rural County & >75% in Farmland

Framework for Service-Learning at Indiana University School of Dentistry Source: YoderKM, J Dent Education,Feb 2006

Remove known barriers between people and oral health services Use service-learning to reduce two common barriers:  Medicaid acceptance: cause students to see, and reflect on, the extent of the effects of disparities in access to care  Dental services for young children: offer service- learning rotations in the 1 st & 2 nd years that allow students to work with very young children (ie. Head Start)

Age Accepted for First Dental Visit: Marion County Dentists (N=286)

 Accelerate recruitment of candidates from underserved rural counties and minority populations  Attempt to retain a greater number of graduates in Indiana Increase oral health workforce adequacy, diversity, and flexibility

 Integrate community based service-learning throughout the curriculum and structure it to enhance clinical and cultural competency skills development  Create a new option or expand the extramural program to encourage exploration of alternative practice settings, (Community health centers, US Public Health Service, International programs) Increase oral health workforce adequacy, diversity, and flexibility

 Continue Counseling students about potential financial incentives for staying in Indiana and practicing in underserved areas & lobby to develop other options ◦ Health Service Corps – loan repayment for working in community health centers ($25 – 35K year tax free) ◦ Explore possibilities for loan repayment options for private practice models serving underserved areas (Washington State) ◦ Lobby for higher Medicaid reimbursement rates for dentists serving special needs populations and underserved geographic areas (Minnesota model) Expand public/private partnerships

 Sister Maura Brannick Chapin Street Health Center  IUSB Dental Education Clinic  Indiana Health Centers  Heart City Dental Clinic Local Dental Clinic Options

 Qualify  Working Poor Clinic  $10 Co-pay per appointment  Reduced Lab Fees  Volunteer DDS and Hygienist Chapin Street Clinic

 Educational Clinic  Reduced Fees  Will file all insurance programs IUSB Dental Education

Indiana Health Centers

 Open to patients of Heart City Health Center. Medicaid and referral from Elkhart Hospital  Income Based  Sliding Fee Schedule- 40% of U and C  Grants from local business and Trustee office Heart City Clinic