Opportunities in Health Reform and Federal Policy Meg Booth, MPH National Maternal & Child Oral Health Policy Center Children’s Dental Health Project Grantmakers In Health Returning the Mouth to the Body: Integrating Oral Health and Primary Care National Maternal & Child Oral Health Policy Center

Goal 1: Enhance Knowledge. Identify, analyze, and promote new information for policymakers and key stakeholders to improve MCH oral health policies and practices. Goal 2: Build Capacity. Build awareness, skills, and knowledge among policymakers and key stakeholders to actively promote new and effective oral health policies. Goal 3: Expand the Community. Expand and diversify the audience engaged in promoting oral health of MCH populations. National Maternal & Child Oral Health Policy Center

W What do we mean by a “health home”?

National Maternal & Child Oral Health Policy Center Medical Home: a physician-directed medical practice that provides point-of-entry enhanced primary care in a continuous fashion across the health care spectrum, and comprehensive, coordinated and delivered in the context of family and community. Dental Home: ongoing relationship between the dentist and the patient inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family-centered way establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate. Health Home: an approach to providing care within service delivery systems integrated, comprehensive medical, dental and mental health care focused on prevention and early intervention with reliance on specialists to help with disease management and provide more intensive care Sources: Patient-Centered Primary Care Collaborative. Patient Centered Medical Home. Accessed 2/1/11 at: homeDefinition of a Dental Home. Policy Statement American Academy of Pediatric Dentistry. Reference Manual. Vol 32; No home Definitions

Health home generally remains a vision as it relates to the integration of dental care, however there are opportunities for integration of medical and dental… Full integration Co-location Shared financing Virtual integration Systems considerations:  Lack of primary care provider training  Lack of dental care provider training  Lack of primary care provider time in well-child visits to provide services beyond physical health  Separate medical and dental financing strategies  Administrative barriers to sharing health information between providers Source: National Maternal and Child Oral Health Policy Center. Children’s Oral Health in the Health Home. May National Maternal & Child Oral Health Policy Center What does a health home look like?

National Maternal & Child Oral Health Policy Center Oral Health in Health Reform (ACA)

Quick Review: National Maternal & Child Oral Health Policy Center Comprehensive systems approach, building on CHIPRA Health coverage bill – estimated by 2019, 92% non-elderly will have health insurance (94% if exclude undocumented immigrants) Provides dental coverage to nearly all children Coverage is supported by numerous additional provisions Unfortunately, many of these provisions still await funding Prevention & Health Promotion Quality Treatment Oral Health Infrastructure & Capacity Community Awareness/Educati on Effective Coverage Family-level Prevention Effective Workforce Child-level disease management Effective Delivery Systems Surveillance, Evaluation, CQI Systems Framework

Prevention & Health Promotion National Maternal & Child Oral Health Policy Center Dental Caries Disease Management Establishes a national grant program to demonstrate the effectiveness of research-based dental caries disease management School-based Dental Sealant Programs Requires that states receive grants for school-based dental sealant programs Oral Health Public Education Campaign Requires HHS Secretary to establish a 5-year public education campaign to promote oral health Prevention and Public Health Trust Fund Establishes a fund to provide an expanded and sustained national investment in prevention and public health programs – may include oral health National Prevention, Health Promotion, and Public Health Council Charged with coordinating Federal prevention policy and developing a national prevention strategic plan Community Transformation Grants Establishes grants to state and local agencies and community organizations for prevention efforts outside the doctor’s office

Effective Coverage National Maternal & Child Oral Health Policy Center Oral Health Services for Children Requires State Exchanges to include oral health services to children, limits on cost sharing on preventive services & income based subsidies may apply Stand-Alone Dental Plans Allows stand-alone dental plans with pediatric benefits to participate in State Exchanges MACPAC Reporting on Dental Payments Requires MACPAC to review payments to dental professionals and report to Congress CHIP MaintenanceFunding made available through FFY15 – increased federal assistance in FFY16, CHIP maintained until 2019 Medicaid ExpansionExpands Medicaid coverage to individuals whose income is 133% of FPL or less.

Workforce and Training National Maternal & Child Oral Health Policy Center Alternative Dental Health Care Providers Establishes a 15-site demonstration project to train or employ alternative dental health care professionals National Health Care Workforce Commission Establishes the Commission and makes the oral health care workforce a high priority for review Dental Training ProgramsEstablishes a number of provisions to promote and encourage the training of dental professionals including loan repayment Primary Care Residency Programs Establishes three-year, $500,000 grants for new primary care residency programs, including oral health Graduate Medical Education Programs Provides funding for new and expanded graduate medical education, including dental education

Delivery System National Maternal & Child Oral Health Policy Center Federally Qualified Community Health Centers Provides funding for construction, capital improvements and service expansions, including dental program expansions School-based Health Centers Provides Grants to SBHCs and includes oral health services in qualified services provided by SBHCs

Infrastructure, Quality & Surveillance National Maternal & Child Oral Health Policy Center Oral Health Infrastructure Requires the CDC to provide cooperative agreements to states for improving oral health infrastructure (from 19 states  50 states, territories, & tribes) Pregnancy Risk Assessment and Monitoring System Requires that oral health measurements be included in PRAMS National Health and Nutrition Examination Survey Retains “tooth-level” surveillance in NHANES Medical Expenditure PanelRequires a “look-back” validation for dental - parity with medical National Oral Health Surveillance System Requires that NOHSS include measurement of early childhood caries and authorizes funding to expand the system to all 50 states

What are the opportunities in ACA to move toward a health home? National Maternal & Child Oral Health Policy Center

Essential Benefits Early Childhood Caries Disease Management Maternal, Infant, and Early Childhood Home Visiting Programs Center for Medicare and Medicaid Innovation School-based Health Centers Dental Training programs ACA Opportunities National Maternal & Child Oral Health Policy Center

Pediatric Dental Benefit – SEC.1302(b)(1)(J) “Pediatric services, including oral and vision care.” Dental benefits can be provided through stand-alone dental plan or qualified health plan. Recommendations to HHS signed by 50+ organizations 1.Effective and efficient dental care for children must be individualized according to their levels of disease risk and disease experience 2.Existing clinical diagnostic and preventive resources should be directed so that the intensity of care received by children is tailored to their levels of disease risk and disease experience in collaboration with the child’s medical home and other community health care agencies. 3.All children should receive pediatric dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions for the attainment and maintenance of oral health. Essential Benefits National Maternal & Child Oral Health Policy Center

SEC – Charges the Secretary to award grants to demonstrate the effectiveness of research-based dental caries disease management activities. Building the evidence-based for dental caries management provides foundation for future efforts to control disease and dental expenditures. Demonstrations would be provided through CDC Eligible entities include community-based provider of dental services –Including FQHCs, hospital clinics, state or local health department, IHS dental program, private dental provider, medical provider, public health provider, nurse, nutrition education institution, or national organization Currently authorized, not appropriated Early Childhood Caries Management Demos National Maternal & Child Oral Health Policy Center

SEC. 2951(SEC. 511 SSA) – amends Title V of Social Security Act to (1) strengthen and improve [Title V] programs and activities…(2)to improve coordination of services for at risk communities; and (3) to identify and provide comprehensive services to improve outcomes for families who reside in at risk communities Statewide needs assessment and coordination with other need assessments and inventory of community-based prevention-focused programs Nurse, social workers, or other professionals meet with at-risk families to evaluate family circumstances and connect families to health care, developmental services, early education, parenting skills, child abuse prevention, and nutrition education or assistance $1.5 billion over five years ($88M awarded 7/11) Maternal, Infant, and Early Childhood Home Visiting National Maternal & Child Oral Health Policy Center

Established by the ACA to rapidly test innovative care and payment models and scale up successful models Designed to be a public/private/consumer partnership to explore new payment and care delivery models in three main areas: –Improved Care for Individuals –Coordinating Care to Improve Health Outcomes for Patients –Community Care Models Projects and initiatives still being developed, exiting initiatives include –Medicaid Health Home State Plan Option –FQHC Advanced Primary Care Practice Demonstration –Multi-Payer Advanced Primary Care Practice Demonstration Appropriated $10 billion over the next 10 years CMS Innovation Center (CMMI) National Maternal & Child Oral Health Policy Center

School-based health centers SEC. 4101(a) – One-time funding for facility construction, expansion, and equipment. $200 million ($50 million per year through FY2013) –Mandatory funding School-based dental sealant program SEC. 4102(b) – Expands existing current school-based dental sealant funding to all 50 states –Currently authorized, not appropriated Community Health Center Trust Fund –SEC (b) – Expand health centers’ operational capacity and enhance their medical, oral, and behavior health services. –$9.5 billion for health center operations (FY2011 through FY2015) –Plus,$1.5 billion for capital needs including new construction and renovation –Mandatory funding School-based Health Care National Maternal & Child Oral Health Policy Center

General, pediatric, and public health dentistry training SEC – –Expands “Title VII” dental workforce training program to include training of dental students and practicing dentists as well as residents –Provides financial assistance to dental trainees (including dental hygienists) developing new training programs –Traineeships and fellowships for dentists committed to teaching; grants for faculty development –Faculty loan repayment programs –Advancing pre-doctoral training in primary care dentistry Current appropriated, partially funded through ARRA and FY10 funding Primary Care Residency Programs SEC – –Establishes three-year, $500,000 grants to establish new primary care residency programs, including dental programs. –Currently appropriated Dental Training Programs National Maternal & Child Oral Health Policy Center

Other Federal Opportunities Children’s Health Insurance Program – –“…coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” –regulations for the dental benefit are anticipated in spring/summer 2012 –benchmark plan for ACA Perinatal Oral Health Services – –State guidelines professional guidelines for perinatal oral health services (NY, CA) –Upcoming national consensus statement (HRSA/MCHB) –Professional training programs

Insignificant support and/or opposition from the dental profession to integrate primary care and dental care Little demand from the public to make changes to the dental delivery system Inconsistent support from dental benefit and health insurers for integrating medical and dental care Limited innovation and adoption of health information technology integrating medical and dental National Maternal & Child Oral Health Policy Center Policy Barriers to Integrating Medical & Dental

National Maternal & Child Oral Health Policy Center What can philanthropy do influence policy change?

National Maternal & Child Oral Health Policy Center Policy Opportunities for Philanthropy Support innovation that addresses system barriers –integrated models of prevention and disease management should drive the discussion about expanding access and quality rather than extensions of the current misdesigned system which will probably yield the same results Build public or political will to make change –There is currently little public demand, provider motivation, or political will to change the dental delivery system –Furthermore, there are active strategies to keep the system the same Encourage policy change that addresses systems barriers –Federal, state or local policy can be changed to encourage or allow integration as innovative models are being tested

National Maternal and Child Oral Health Policy Center – Children’s Dental Health Project – Meg Booth National Maternal & Child Oral Health Policy Center Children’s Dental Health Project Ph Resources National Maternal & Child Oral Health Policy Center