CURRENT STATUS OF CURRENT STATUS OF DENTAL CARE FOR THE DENTAL CARE FOR THE

UNDERSERVEDUNDERSERVED

SAFETY NET SUMMITSAFETY NET SUMMITUTAH DEPARTMENT OF HEALTHUTAH DEPARTMENT OF HEALTH

MAY 19, 2009MAY 19, 2009

Bruce P. Murray, Ph.D., Bruce P. Murray, Ph.D., FACHE, CAEFACHE, CAE

AGENDAAGENDA

1. The recession is impacting U.S. dental 1. The recession is impacting U.S. dental underserved & dentists.underserved & dentists.

2.2. Who are Utah’s dental underserved? Who are Utah’s dental underserved?3. Who are Utah’s safety net dental providers?3. Who are Utah’s safety net dental providers?4. The recession is impacting Utah’s dental 4. The recession is impacting Utah’s dental

underserved & dentists.underserved & dentists.5. Conclusions & questions/answers.5. Conclusions & questions/answers.

DDYNAMICS OF THE DENTAL CARE MILIEUYNAMICS OF THE DENTAL CARE MILIEU

LAWMAKERS& CMS

OFFICIALS

RECESSION

SAFETY NET DENTISTS

PATIENTS>UNINSURED

>UNDERINSURED

HOSPITAL E.R.S$$$

PRIVATE DENTISTS

>Budget Deficit>Medicaid $

>Federal Stimulus $

TAXPAYERS

>Uncompensated Care(Bad Debt/Charity Care)

>Cost Shift(Business Owners;

Insurers; Higher Premiums)

TAXPAYERS

UNEMPLOYMENT

IMPACT ON DENTAL PATIENTSIMPACT ON DENTAL PATIENTS

Typology of patients’ changing utilization behaviors: Typology of patients’ changing utilization behaviors:

Uninsured able to payUninsured able to pay —no change; pay out-of-pocket; —no change; pay out-of-pocket; reduce usage; delay electivesreduce usage; delay electives

Insured (employer or private dental plans)Insured (employer or private dental plans) —no change; —no change; reduce usage; delay electivesreduce usage; delay electives

Underinsured (Medicaid, PCN, Chip, Medicare, etc.)Underinsured (Medicaid, PCN, Chip, Medicare, etc.) — —”get it while you can;” reduce usage; delay usage;”get it while you can;” reduce usage; delay usage;pay out-of-pocket(?); seek charity care; go withoutpay out-of-pocket(?); seek charity care; go without

Uninsured unable to payUninsured unable to pay —seek charity care at —seek charity care at hospital E.R.s and/or free clinics; go withouthospital E.R.s and/or free clinics; go without

PATIENTS DOING THEIR OWN DENTISTRYPATIENTS DOING THEIR OWN DENTISTRY

--Supergluing teethSupergluing teeth—”It’s one of my front —”It’s one of my front teeth, I have just been supergluing it in!”teeth, I have just been supergluing it in!”

--Pulling out bad teethPulling out bad teeth—”They’ll pull it —”They’ll pull it themselves rather than have it fixed.”themselves rather than have it fixed.”

--Taking leftover medicationsTaking leftover medications—”They take —”They take a family member’s old pain pills or a family member’s old pain pills or leftover antibiotics.”leftover antibiotics.”

--Buying street drugs for painBuying street drugs for pain—”More & —”More & more people are buying street drugs, not more people are buying street drugs, not just for addictions.”just for addictions.”

--Scrimping on looksScrimping on looks——”They are putting ”They are putting off bleaching or other restorative off bleaching or other restorative procedures.”procedures.”

PATIENTS & DENTISTS BARTERINGPATIENTS & DENTISTS BARTERING

Patients/dentists are Patients/dentists are bartering to receive/provide bartering to receive/provide services, e.g.,services, e.g.,

-trading baseball cards, -trading baseball cards, watches, cupcakes/cookies, watches, cupcakes/cookies, artwork, bicycles, a dog, artwork, bicycles, a dog, flowers, plumbing/electrical flowers, plumbing/electrical services, a meal at a favorite services, a meal at a favorite restaurant, etc.restaurant, etc.

PATIENTS’ SEEKING EXPENSIVE PATIENTS’ SEEKING EXPENSIVE TREATMENT AT HOSPITAL E.R.STREATMENT AT HOSPITAL E.R.S

-Denti-Cal cuts for 8.5M persons -Denti-Cal cuts for 8.5M persons threaten overall health & inundate E.R.s threaten overall health & inundate E.R.s -E.R. cost of -E.R. cost of $6,498$6,498 vs. Dental Office preventive cost vs. Dental Office preventive cost of of $660$660 1/29/09 Article – CA Dent Hyg Assn.1/29/09 Article – CA Dent Hyg Assn.

-4 yr. study comparing -4 yr. study comparing preprechange & change & postpostchange cuts to Medicaid funding in change cuts to Medicaid funding in Maryland Maryland -Postchange rate of E.D. claims -Postchange rate of E.D. claims was was 12% higher12% higher than prechange than prechange 2002 JADA Article—Cohen, et al.,2002 JADA Article—Cohen, et al.,

IMPACT ON DENTISTSIMPACT ON DENTISTS22ndnd ADA ADA “Survey of Economic Confidence”“Survey of Economic Confidence”

1,699 dentists—Q3-2008 VS. Q4-2008 responses1,699 dentists—Q3-2008 VS. Q4-2008 responses

More reported decreased incomes --53.0% vs. 58.1%More reported decreased incomes --53.0% vs. 58.1%Fewer reported higher incomes --18.0% vs.14.6%Fewer reported higher incomes --18.0% vs.14.6%More reported decrease in gross billings --46.5% vs. 50.1%More reported decrease in gross billings --46.5% vs. 50.1%More reported increase in avg. A/R days --24.4% vs. 26.4% More reported increase in avg. A/R days --24.4% vs. 26.4%

””Three things happen in every recession: sales decline, receivables Three things happen in every recession: sales decline, receivables increase and credit tightens. . . .Dentists who think they will fly through increase and credit tightens. . . .Dentists who think they will fly through the current recession on autopilot will be sorely mistaken!”the current recession on autopilot will be sorely mistaken!” —Dr. Michael Schuster, —Dr. Michael Schuster, The Science of Creating WealthThe Science of Creating Wealth, 2008., 2008.

PROVIDER ADJUSTMENTSPROVIDER ADJUSTMENTS(Examples)(Examples)

Have PMA & Work with the “right” dental teamHave PMA & Work with the “right” dental team

Develop creative payment methodsDevelop creative payment methods

Know & monitor practice numbersKnow & monitor practice numbers

Buy-out & close a nearby practiceBuy-out & close a nearby practice

Market services more effectivelyMarket services more effectively

Hone patient service skillsHone patient service skills

(chair-side & follow-ups)(chair-side & follow-ups)

Reduce broken appointmentsReduce broken appointments

WHO ARE UTAH’SWHO ARE UTAH’S DENTAL UNDERSERVED? DENTAL UNDERSERVED?

Persons Persons “supplied with inadequate/insufficient services, “supplied with inadequate/insufficient services, esp. medical and dental.”esp. medical and dental.” --Surgeon General, 2000--Surgeon General, 2000

Includes 5 populations:Includes 5 populations: -Family incomes below 200% FPL-Family incomes below 200% FPL -Medical disability/chronic illness-Medical disability/chronic illness -Geographically isolated and underserved-Geographically isolated and underserved -Limited literacy-Limited literacy -Confined to residential settings-Confined to residential settings

——RWJohnson Foundation, 2008.RWJohnson Foundation, 2008.

HOW MANY UTAHHOW MANY UTAHDENTAL UNDERSURVED?DENTAL UNDERSURVED?

Potentially Potentially 47.8%47.8% (1.4M) of UT’s Total (1.4M) of UT’s Total Population of 2.8M as of 7/1/08 Population of 2.8M as of 7/1/08 --Extrapolations from Surgeon General’s Report, --Extrapolations from Surgeon General’s Report, 2000 2000 & current enrollment tallies& current enrollment tallies

Estimated Estimated 34.0%34.0% (952,000) did not visit a (952,000) did not visit a dentist in 2008 dentist in 2008 --Gallup Poll of 355,334 Americans, USA Today, 2008.--Gallup Poll of 355,334 Americans, USA Today, 2008.

CHANGING USAGE PATTERNS OF CHANGING USAGE PATTERNS OF UTAH’S DENTAL UNDERSERVED UTAH’S DENTAL UNDERSERVED

(Examples)(Examples)

More seeking Medicaid & more uninsuredMore seeking Medicaid & more uninsuredMore families & children seeking careMore families & children seeking careMore referralsMore referralsMore demands for primary servicesMore demands for primary servicesLonger wait-times & more turned awayLonger wait-times & more turned awayMore violence in waiting linesMore violence in waiting linesFewer nursing home patientsFewer nursing home patients

CHANGES TO UTAH’S SAFETY NETCHANGES TO UTAH’S SAFETY NET DENTAL PROVIDERS’ PROGRAMS DENTAL PROVIDERS’ PROGRAMS

(Examples)(Examples)

Fewer services—dentures & RTCsFewer services—dentures & RTCsLosing patient base & O.R. Specialty ServicesLosing patient base & O.R. Specialty ServicesUndermining of patient recruitment effortsUndermining of patient recruitment effortsClinics placed in mothballs or closedClinics placed in mothballs or closedMoratorium on hiring new employeesMoratorium on hiring new employeesLosing incentives, loan repayment & personnelLosing incentives, loan repayment & personnelEmployees concerned w/ viability of NFPsEmployees concerned w/ viability of NFPsLosing grant funds to subsidize programsLosing grant funds to subsidize programsHygiene programs receiving more applicantsHygiene programs receiving more applicants

UTAH SAFETY NET DENTAL UTAH SAFETY NET DENTAL PROVIDERS’ ADJUSTMENTSPROVIDERS’ ADJUSTMENTS

(Examples)(Examples)

Develop creative payment programsDevelop creative payment programsImprove marketing effortsImprove marketing effortsRefer patients elsewhereRefer patients elsewhereCommunicate better with patientsCommunicate better with patientsFind ways to enhance employee morale & retentionFind ways to enhance employee morale & retentionApply for more grant $$Apply for more grant $$Accept more students to dental hygiene programsAccept more students to dental hygiene programsFoster scheduling flexibility & modify admitting policyFoster scheduling flexibility & modify admitting policyAcquire more donated equipmentAcquire more donated equipment

CONCLUSIONSCONCLUSIONS

1. Dental underserved numbers are increasing alarmingly 1. Dental underserved numbers are increasing alarmingly as unemployment rises.as unemployment rises.

2.2. Current status of dental care for the underserved is Current status of dental care for the underserved is undesirable & getting worse. undesirable & getting worse.

3. Dental underserved are not well informed about 3. Dental underserved are not well informed about preventing dental emergencies.preventing dental emergencies.

4. Private dentists are accepting fewer underserved.4. Private dentists are accepting fewer underserved.5. Safety net is deteriorating rapidly & portions of it may 5. Safety net is deteriorating rapidly & portions of it may

be on the brink of collapsing altogether. be on the brink of collapsing altogether. 6. Hospitals are being forced to become the ultimate, very 6. Hospitals are being forced to become the ultimate, very

expensive safety net for the underserved.expensive safety net for the underserved.7. Perseverance in delivering dental services to the 7. Perseverance in delivering dental services to the

underserved is critical now for all involved.underserved is critical now for all involved.

Proverbs 29:18Proverbs 29:18

““Where there is no vision (relationship Where there is no vision (relationship of dental health to overall health), the of dental health to overall health), the people people perish. . . .”perish. . . .”

QUESTIONS & ANSWERSQUESTIONS & ANSWERS

THANK YOU!THANK YOU!