BY Jan Gabriel, Project Coordinator 11-11-99
The Red River Region Community Dental Access Committee (herein, called the Committee) was formed in 1997 to address a critical and growing problem of access to oral health care in a 25 county region, primarily by low-income families, children and the elderly. The goal of the Committee "is to improve access to basic and urgent dental care for families and children in the Red River valley who are living below 200% of the poverty level, the uninsured, the homeless population, Native Americans, seasonal farm workers and recent refugees."
The Committee is composed of health and dental professionals; legislators; representatives from Minnesota and North Dakota Departments of Health and Departments of Human Services: representatives from local human service programs; county health departments; Dakota Medical Foundation; Managed Care representation from Minnesota; Northwest Technical College, University of Minnesota Dental School; and non-profit community dental service providers.
The catchment area for the Dental Access Committee and dental access improvements is a 14 county area in North Dakota and a 10 county area in Minnesota within an 80-mile radius of the Fargo-Moorhead area. The catchment area encompasses the Red River, which runs on the border between North Dakota and Minnesota. The region encompasses North Dakota's most populous areas and Minnesota's more rural areas.
Just under one-half (45%) of North Dakota's population resides in the catchment area while 5.1% of Minnesota's population resides in the area. Of the state Medicaid population, 38 percent (24,000) of North Dakota's eligibles reside in the catchment area, while in Minnesota 7.1 percent (53,000) of the Medicaid eligibles reside in the area. Of the Minnesota eligibles, 51 percent are enrolled in a managed care program. North Dakota currently does not have a managed care program for dental services. The Committee is concerned about dental access for the 77,000 Medicaid eligibles in the region along with the uninsured working poor, and special populations. Special populations include: Native Americans, migrant workers, the disabled, the elderly, and refugees settling in the region. These populations may have difficulty with mobility, transportation, use of the English language, and a lack of basic education about dental care.
Children are of major concern. It has been proven that early dental screenings and preventive procedures can prevent most dental diseases. The American Dental Association recommends that children first see a dentist by the age of one. Head Start programs that serve children from 0-5, are required to provide dental screenings, but have difficulty finding a dentist to do the screenings and any subsequent follow-up procedures.
Approximately 10 percent of young children in North Dakota age 3-5 suffer from a severe form of dental caries called baby bottle tooth decay. Among Native American children, the baby bottle tooth decay rate is three times greater at 29 percent. Twenty-five percent of 6-8 year olds and 22 percent of 15 year olds have untreated caries and the rate for Native American children is twice as high. A North Dakota statewide survey of low-income families indicated the major reasons for not seeking dental care was cost and an inability to find providers to treat them, as well as a lack of awareness of preventive dental care.
SUMMARY OF NEED
In the past few years, State, local, and private agencies have begun initiatives to improve the participation of dentists in Medicaid and to encourage children and families to use dental services. State initiatives include: (1) increased reimbursement rates, (2) managed care arrangements, (3) streamlined claims processing. (4) outreach and beneficiary education, (5) mandated provider participation, (6) training general dentists and non-dental health providers, (public and private non-profit clinics for dental care, and (8) donated voluntary efforts by dentists. (Source: Children's Dental Services Under Medicaid Access and utilization, Office of Inspector General, Department of Health and Human Services April 1996).
In North Dakota, a federally designated community health clinic has been established (the Family Health care Center) that began offering dental services during the fall of 1995. An expansion of dental services to the Moorhead site of the Family Health Care Center is planned for the fall of 1999. Funding has been secured.
Reimbursement rates were increased in late 1997 in North Dakota to 87.4% of billed charges for children and adults at 74.4% of billed charges. Minnesota recently increased its reimbursement rates by 3% to 56% of usual and customary charges. Minnesota has also implemented incremental increases in reimbursement rates over the past 10 years and included a rural health care access fee under managed care plans for Medicaid populations. All health care providers pay these access fee funds, but dental professionals complain that little comes back for dental services.
Although the need for dental services is increasing in eastern North Dakota, especially for Medicaid eligible persons, the need in northwest and northcentral Minnesota is even more critical. A report completed by the Department of Human Services in 1998 includes utilization data encompassing all 87 counties that measures receipt of at least one dental service per 1,000 member months. It showed for recipients enrolled in managed care, all six of the counties in the lowest usage rate are in the Red River area and for non-managed care (fee-for-service) recipients, three of the seven counties in the lowest usage rate are in the Red River area. Clay County is one of the two counties in Minnesota with the lowest utilization rate of 9 percent or less of eligible recipients. This means that less than 10 per cent of all Medicaid eligible recipients in Clay County are able to access dental care.
Dental manpower is also of significant concern for the future. In a survey done by the North Dakota Department of Health, over 40 percent of dentists plan to retire or sell their practice within the next 10 years. Over 25 percent of Minnesota dentists plan to retire or sell within the next ten years. With no dental school in ND, and enrollment dropped to 86 students at the University of Minnesota Dental School, attracting adequate numbers of providers to both states will be a major challenge.
The number of general dentists being trained nationwide is also on the decline. Dental schools are closing and the availability of loan repayment and scholarship funds has greatly decreased since the 1980's. Seven dental schools have closed, one has opened, and another has recently been approved in Nevada. As all states face dentist shortages, the need for more slots in dental schools will grow along with competition to attract dentists to individual locations, primarily in rural states like North Dakota and Minnesota.
The population to dentist ratio for North Dakota in the Red River Region is 2155:1 and the ratio for the Red River Region in Minnesota is 2419:1. Both regions have ratios more than the US average of 1859:1. To make matters worse, only 3 percent of the dental providers in the state of Minnesota practice in west central Minnesota (an eleven county area of eighty-seven counties in Minnesota).
Findings from a 1996 needs assessment survey, conducted by Southeastern North Dakota Community Action Agency ranked access for dental care among the top three unmet needs of low-income families in southeastern ND. Less than 24 percent of the dentists in the region accept Medicaid patients on a regular basis. Anecdotal evidence shows that many families covered under Medicaid or a managed care program have to spend several hours on the phone to locate a dentist who will provide dental services. Many families have to travel 20-60 miles to access dental care, and this can be very difficult if follow-up appointments are needed.
Dental providers state that the three primary reasons dentist will not accept Medicaid patients is:
- low-reimbursement rates
- failure of clients to keep appointments, and
- Poor attitudes and lack of patient compliance with treatments.
In North Dakota, 68 percent of the adults in the general population visit the dentist each year while only 30 percent of the Medicaid eligible recipients see the dentist each year. For children, the statistics are only slightly better. 81 percent of all children visit the dentist yearly, while only 34 percent of the Medicaid eligible children visit a dentist each year.
In Minnesota, 76 percent of the adults in the general population visit the dentist each year while the Medicaid utilization rate for adults is 40 percent (26.4 for the fee-for-service program and 13.6 percent in the managed care program). For children, 78 percent of all children visit the dentist yearly, while only 52.4 percent of Medicaid eligible children visit the dentist yearly (26.3 percent for the fee-for-service program and 26.1 percent for the managed care program).
EXISTING SERVICES THAT ADDRESS THE NEEDS
A. Family Health Care Center in Fargo, North Dakota
The Family Health Care Center is the only community health center in North Dakota. While the center does have a dental clinic, its current capacity is inadequate to meet the need. Clients must wait 4-6 months for appointments for non-urgent care and the requests for emergency or urgent care exceed 8 per day. The center only has two part time dentists and a part time hygienist. In 1998 the center served 1558 dental clients for a total of 2,945 visits.
B. Family Health Care Center in Moorhead, Minnesota
The Family Health Care Center in Moorhead currently (9-1-99) does not have dental services. It has recently received funding from the Minnesota Department of Human Services to complete renovations and purchase dental equipment. Construction should begin in November. The Center received a $180,000 grant over two years from Dakota Medical Foundation in August 1999 for startup costs for the dental clinic expansion.
C. Apple Tree Dental at Hawley, Minnesota
In 1997 Apple Tree Dental based in Minneapolis expanded its dental services and mobile care program to the five county area east of Moorhead. Over 20,000 Medicaid eligible recipients resided in the area but private dentists were only providing care to about 100 patients per month. The Hawley clinic consists of two dentists, a hygienist, two dental assistants, and an office manager. Medicaid recipients are served at the Hawley Clinic and at seven satellite sites in the region—primarily nursing homes. They recently received a grant of $220,000 to expand the clinic's equipment and purchase an additional mobile van.
D. Northwest Technical College
Northwest Technical College started its Dental Assistant program in 1972 at its campuses in Moorhead and Bemidji. The Dental Hygienist program started in Moorhead in 1995. The Moorhead campus does not have a full time dentist, so services are limited. They use part time adjunct dentists as faculty and generally do not do restorative work, dentures, denture repairs, or provide emergency services. Their target populations include: students, NTC staff and faculty, Moorhead State University Health Center referrals, migrants, and children in Head Start Programs. The students and supervising dentists provide dental services to about 1,500 patients each year. The dental students could provide more dental services if they had adequate supervision by dentists or could work more independently without supervision. Tech students go on rotations to other sites and expansion is possible. A Minnesota Department of Human Services initiative passed by the 1999 Minnesota Legislature will allow some pilot projects to allow dental hygienists to work in non-traditional sites to provide dental services without direct supervision. Clay County applied on behalf of NW Tech and Apple Tree Dental, but was denied funding for a pilot project.
E. North Dakota State School of Science at Wahpeton
SSS has a two-year dental hygienist program and a one-year dental assistant program. They have a full time dentist on staff and have 56 dental hygienist students and 18 dental assistant students at any one time. The school sees 4500 patients from the Wahpeton-Breckenridge area each year. They take private pay, MA and private insurance recipients. They serve 200 Indian students at the Circle of Nations School in Wahpeton, and serve the Head Start children in Breckenridge. They also see over 150 migrant children each summer. Students get most of their practical experience on campus, but students also go to the Fargo VA hospital and the St. Frances nursing home daily. All students do affiliations at these centers or with private dental offices. Many local dentists, who are too busy to do hygienist services, make referrals to the school.
F. Private Practice Dental Initiatives
Many dentists report that they take Medical Assistance recipients or other low-income persons in their practices on a limited basis. Most do not charge or provide services for reduced prices. These same dentists do not participate in the managed care programs because of the low reimbursements and hassles with paperwork and limitations of services they can provide. They feel they are doing their part but are reluctant to let the public know they do this for fear of too many calls for free service.
In 1995 an Emergency Dental Call System was developed at Dakota Hospital (now, Dakota Heartland). A dental office was established and dentists were called on a rotating basis. The system failed in 1997 when some dentists complained they were being called too often and that all dentists were not participating. Dakota Hospital became Dakota Heartland, a for-profit hospital and they discontinued the clinic due to costs, inability to find enough dentists to participate, and concerns about repeat patients requesting narcotics for pain, whether they needed it or not.
Through the National Foundation of Dentistry for the Handicapped in Denver, Colorado, North Dakota and Moorhead have shown an interest in setting up a Donated Dental Services project in the North Dakota and Moorhead, MN area. The project would utilize donated dental office of at least 40 dentists and 5 laboratories and would be staffed with a coordinator. This was a proposal submitted to the Dakota Medical Foundation in September 1998. No action has been taken.
G. University of Minnesota Dental School Initiatives
- Practice Opportunity Fairs
- Placement Information Programs
- National Recruitment and Retention Networks
- Externship and Preceptorship programs – dental students would rotate to a dental practice. Would need coordination from the Dental Associations, the Board of Dentistry, and the Legislature. Would need local dentists as faculty
- Regional Dental School (ND,MN,SD) U of M would serve as core site with satellite clinics in each state.
- H. State Dental Association Initiatives
- Mentorship programs for dental students at the U of M and local community dentists
- Recruitment of dentists and their spouses.
- Legislative initiatives