1. Implementing Change in Oral Health Policy: Lessons Learned Stephen Beetstra, DDS Arkansas Children’s Hospital

2. Implementing Change in Oral Health Policy Change occurs when a problem has been identified and public opinion demands a solution. Change occurs when a problem has been identified and public opinion demands a solution. Most successful policy changes begin locally and move up through the state and federal systems. Most successful policy changes begin locally and move up through the state and federal systems.

3. Implementing Change in Oral Health Policy Do your research. Come across as an expert and a resource for the policy makers. Do your research. Come across as an expert and a resource for the policy makers. Think broadly about who the policy change will effect. Think broadly about who the policy change will effect. Develop collaborative relationships with other organizations before pushing for a policy change. Develop collaborative relationships with other organizations before pushing for a policy change.

4. Implementing Change in Oral Health Policy Inquire with local, state, and federal leaders if change is possible under the current political environment. Inquire with local, state, and federal leaders if change is possible under the current political environment. When meeting with policy makers, discuss the problem, but also possible (multiple) solutions When meeting with policy makers, discuss the problem, but also possible (multiple) solutions Come with cost estimates. Come with cost estimates. A cost benefit analysis will determine if changes in policy will occur. A cost benefit analysis will determine if changes in policy will occur.

5. Implementing Change in Oral Health Policy Strike when the iron is hot. Use current events to help strengthen your position. Strike when the iron is hot. Use current events to help strengthen your position. Demonte Driver Demonte Driver Be prepared to defend your position intelligently when adversity strikes. Be prepared to defend your position intelligently when adversity strikes. North Little Rock Toddler North Little Rock Toddler

6. Access Issues Dental Medicaid Fee Increases Dental Medicaid Fee Increases Pro Pro Federal Match Federal Match Increase in non traditional practices Increase in non traditional practices Initial support from the dental community Initial support from the dental community Increase in Access Increase in Access Assists in support for safety net system Assists in support for safety net system Medicaid programs can manipulate quantity of services by fee schedules Medicaid programs can manipulate quantity of services by fee schedules

7. Access Issues Cons Cons Sometimes not supported by other Health professionals Sometimes not supported by other Health professionals Viewed as a quick fix by many lawmakers Viewed as a quick fix by many lawmakers Increase in non traditional practices Increase in non traditional practices Becomes a perceived threat to traditional dental practices because of corporate involvement Becomes a perceived threat to traditional dental practices because of corporate involvement Allegations of cherry picking and patient dumping between providers and practices Allegations of cherry picking and patient dumping between providers and practices Fee schedules determine what services will be provided Fee schedules determine what services will be provided

8. Access Issues Bottom Line with Medicaid Fee Increases Bottom Line with Medicaid Fee Increases 1. Significant increases in preventive services for patients 2. Strengthens already established safety net providers 3. Slight increase in restorative and emergency services 4. If already established traditional practice, chances are they will not participate even with fee increase.

9. Access Issues Bottom Line with Medicaid Fee Increases Bottom Line with Medicaid Fee Increases 5. Corporate practices will develop quickly due to fee increases 6. Cost of program will increase significantly for the State 7. Mobile dental practices begin to appear 8. Due to competition for staff, pay rates increase for assistants, hygienists, and staff dentists

10. Case Studies Problem One: No Access For Anyone

11. Hidalgo County Demographics County Population – 7500 County Population – 7500 Home of the Gray Ranch Home of the Gray Ranch Sixty miles from anywhere Sixty miles from anywhere Hospital Closed in the 1970’s (Hill-Burton) Hospital Closed in the 1970’s (Hill-Burton) Home to two prisoner of war camps in WWII Home to two prisoner of war camps in WWII Current major employer is the Public Schools Current major employer is the Public Schools

12. Hidalgo Medical Services Started in 1994 after no medical providers were in the county for more than 10 years. Started in 1994 after no medical providers were in the county for more than 10 years. State and Federal Support were necessary to get program started. State and Federal Support were necessary to get program started. Initial mission was to provide health care to an underserved population. Initial mission was to provide health care to an underserved population. Mission drastically changed when Phelps- Dodge closed the smelter at Playas in 1998. Mission drastically changed when Phelps- Dodge closed the smelter at Playas in 1998.

13. Hidalgo Medical Services Community survival and economic development became the major focus of the organization. Community survival and economic development became the major focus of the organization. Primary Goal became economic development. Primary Goal became economic development. Second largest employer in the county. Second largest employer in the county. Largest construction project in 20 years. Largest construction project in 20 years. Used local taxes to pay for improvements Used local taxes to pay for improvements

14. Hidalgo Medical Services Results Results Largest primary care provider in Southwest New Mexico Largest primary care provider in Southwest New Mexico Currently 4 dentists, 4 hygienists, 10 assistants, and part time orthodontist Currently 4 dentists, 4 hygienists, 10 assistants, and part time orthodontist May re-open the hospital for an acute care inpatient facility May re-open the hospital for an acute care inpatient facility Expanded services to four other communities Expanded services to four other communities Was able to persuade Department of Homeland Security to open training site Was able to persuade Department of Homeland Security to open training site

15. Case Studies Problem Two: No Access for Medicaid Recipients

16. Background In 2000, a community leader from the Barrio complained to Senator Bingaman about lack of dental care for children. In 2000, a community leader from the Barrio complained to Senator Bingaman about lack of dental care for children. No pediatric dentists in Eastern New Mexico. No pediatric dentists in Eastern New Mexico. Two dentists accept Medicaid. One 60 miles away, the other 100. Two dentists accept Medicaid. One 60 miles away, the other 100. Met with local dentists about issues. Met with local dentists about issues.

17. Background Dentist Concerns Dentist Concerns Practices at capacity Practices at capacity Lack of support staff Lack of support staff High missed appointment rates High missed appointment rates Unable to refer patients to specialists for complex cases Unable to refer patients to specialists for complex cases Unable to recruit dentists to community Unable to recruit dentists to community

18. Roswell Dental Project Collaboration between Eastern New Mexico University-Roswell, University of New Mexico, NM Department of Health,Chaves County, and City of Roswell Collaboration between Eastern New Mexico University-Roswell, University of New Mexico, NM Department of Health,Chaves County, and City of Roswell Roswell used the project to make it an All American City Roswell used the project to make it an All American City Used creation of dental education programs at all levels to increase access to underserved populations Used creation of dental education programs at all levels to increase access to underserved populations

19. Roswell Dental Project Create access and training to and from specialists for local providers. Create access and training to and from specialists for local providers. Create hospital program Create hospital program The Dental Van Project The Dental Van Project New Facility in 2008 New Facility in 2008 Residency expansion in 2009 Residency expansion in 2009 Three new dentists in the community since projected started Three new dentists in the community since projected started

20. Roswell Dental Project Major Funding of the project came from Federal and State Governments, and W.K. Kellogg Foundation, Community Voices Project Major Funding of the project came from Federal and State Governments, and W.K. Kellogg Foundation, Community Voices Project Barriers during project Barriers during project Dentist Dentist Other Community College Other Community College Staffing Staffing

21. Case Studies Problem Three: Community Water Fluoridation

22. Henderson County Statistics Population – 70,000 Population – 70,000 Hendersonville City Water System – 47,000 Hendersonville City Water System – 47,000 Known as the “City of Four Seasons” Known as the “City of Four Seasons” Population either affluent or poor, very small middle class Population either affluent or poor, very small middle class

23. Fluoridation Largest water system not fluoridated in North Carolina Largest water system not fluoridated in North Carolina Failed in the early 60’s, 70’s, and 80’s. Failed in the early 60’s, 70’s, and 80’s. Caries rates 40% higher in low income population than the rest of the state Caries rates 40% higher in low income population than the rest of the state

24. Fluoridation Battle of 1996 Talked with Parents and Providers about what I was seeing in clinic Talked with Parents and Providers about what I was seeing in clinic Talked to Community Partners to see if they would support the initiative Talked to Community Partners to see if they would support the initiative Called State Dental Director and Dean of the Dental School for Assistance Called State Dental Director and Dean of the Dental School for Assistance Obtained Cost information for fluoridation equipment Obtained Cost information for fluoridation equipment

25. Fluoridation Battle of 1996 Obtained grant information for City Officials Obtained grant information for City Officials Met with the Mayor, and each city council person individually Met with the Mayor, and each city council person individually Was able to have issue placed on council agenda Was able to have issue placed on council agenda

26. Fluoridation Battle of 1996 Pro Pro Dental Association Dental Association Medical Association Medical Association School Board School Board Board of Health Board of Health Head Start Head Start Council on Aging Council on Aging State Agencies State Agencies Local Newspaper Local Newspaper Churches Industries Chamber of Commerce Civic Organizations

27. Fluoridation Battle of 1996 Anti Anti Henderson County Coalition to Prevent Water Fluoridation Henderson County Coalition to Prevent Water Fluoridation One Chiropractor One Chiropractor

28. Fluoridation Battle of 1996 Initial City Council Meeting Initial City Council Meeting Public Hearing in Armory Public Hearing in Armory Anti-fluoridation Summit Anti-fluoridation Summit Meeting with City Councilmen Meeting with City Councilmen Protests Protests Harassments Harassments Picketing Picketing Vote Vote Lawsuit Lawsuit

29. Fluoridation Battle of 1996 Aftermath Aftermath Coalition membership Coalition membership Ice storm Ice storm Sealant Program Sealant Program

30. Stephen Beetstra, DDS Arkansas Children’s Hospital beetstrasm@archildrens.org