Did Access to Care Improve Since Passage of the Veterans Choice Act?: Differences Between Rural and Urban Veterans.

BACKGROUND: The 2014 Veterans Choice Program aimed to improve care access for Veterans through expanded availability of community care (CC). Increased access to CC could particularly benefit rural Veterans, who often face obstacles in obtaining medical care at the Veterans Health Administration (VHA). However, whether Veterans Choice Program improved timely access to care for this vulnerable population is understudied. OBJECTIVES: To examine wait times among rural and urban Veterans for 5 outpatient specialty care services representing the top requests for CC services among rural Veterans. RESEARCH DESIGN: Retrospective study using VHA and CC outpatient consult data from VHA's Corporate Data Warehouse in Fiscal Year (FY) 2015 (October 1, 2014 to September 30, 2015) and FY2018 (October 1, 2017 to September 30, 2018). SUBJECTS: All Veterans who received a new patient consult for physical therapy, cardiology, optometry, orthopedics, and/or dental services in VHA and/or CC. MEASURES: Wait time, care setting (VHA/CC), rural/urban status, sociodemographics, and comorbidities. RESULTS: Our sample included 1,112,876 Veterans. Between FY2015 and FY2018, mean wait times decreased for all services for both rural and urban Veterans; declines were greatest in VHA (eg, mean optometry wait times for rural Veterans in VHA vs. CC declined 8.3 vs. 6.4 d, respectively, P<0.0001). By FY2018, for both rural and urban Veterans, CC mean wait times for most services were longer than VHA wait times. CONCLUSIONS: Timely care access for all Veterans improved between FY15 and FY18, particularly in VHA. As expansion of CC continues under the MISSION Act, more research is needed to evaluate quality of care across VHA and CC and what role, if any, wait times play.

Impact of Medicaid Policy on the Oral Health of Publicly Insured Children.

Objective Fluoride varnish (FV) applications among non-dentist primary care providers has increased due to state Medicaid policies. In this study we examine the impact of FV policies on the oral health of publicly insured children aged 2-6 years old. Methods Using three waves of the National Survey of Children's Health (2003, 2007, 2011/12), we used a logistic regression model with state and year fixed effects, adjusting for relevant child characteristics, to examine the association between years since a state implemented a FV policy and the odds of a publicly insured child having very good or excellent teeth. We compared children with public insurance in states with FV policies to children with public insurance in states without FV policies, controlling for the same difference among children with private insurance who were unlikely to be affected by Medicaid FV policies. Results Among 68,890 children aged 2-6 years, 38% had public insurance. Compared to privately insured children, publicly insured children had significantly lower odds of having very good or excellent teeth [odds ratio (OR) 0.70, 95% CI 0.62-0.81]. Publicly insured children in states with FV policies implemented for four or more years had significantly greater odds of having very good or excellent teeth (OR 1.28, 95% CI 1.03-1.60) compared to publicly insured children in states without FV policies. Conclusions for Practice State policies supporting non-dental primary care providers application of FV were associated with improvements in oral health for young children with public insurance.

Using Registered Dental Hygienists to Promote a School-Based Approach to Dental Public Health.

We examine a strategy for improving oral health in the United States by focusing on low-income children in school-based settings. Vulnerable children often experience cultural, social, economic, structural, and geographic barriers when trying to access dental services in traditional dental office settings. These disparities have been discussed for more than a decade in multiple US Department of Health and Human Services publications. One solution is to revise dental practice acts to allow registered dental hygienists increased scope of services, expanded public health delivery opportunities, and decreased dentist supervision. We provide examples of how federally qualified health centers have implemented successful school-based dental models within the parameters of two state policies that allow registered dental hygienists varying levels of dentist supervision. Changes to dental practice acts at the state level allowing registered dental hygienists to practice with limited supervision in community settings, such as schools, may provide vulnerable populations greater access to screening and preventive services. We derive our recommendations from expert opinion.

Does Restriction of Public Health Care Dental Benefits Affect the Volume, Severity, or Cost of Dental-Related Hospital Visits?

PURPOSE: On July 1, 2012, the Illinois legislature passed the Save Medicaid Access and Resources Together (SMART) Act, which restricts adult public dental insurance coverage to emergency-only treatment. The purpose of this study was to measure the effect of this restriction on the volume, severity, and treatment costs of odontogenic infections in an urban hospital. MATERIALS AND METHODS: A retrospective cohort study of patients presenting for odontogenic pain or infection at the University of Illinois Hospital was performed. Data were collected using related International Classification of Diseases, Ninth Revision codes from January 1, 2011 through December 31, 2013 and divided into 2 cohorts over consecutive 18-month periods. Outcome variables included age, gender, insurance status, oral and maxillofacial surgery (OMS) consultation, imaging, treatment, treatment location, number of hospital admission days, and inpatient care level. Severity was determined by the presence of OMS consultation, incision and drainage, hospital admission, and cost per encounter. Hospital charges were used to compare the cost of care between cohorts. Between-patients statistics were used to compare risk factors and outcomes between cohorts. RESULTS: Of 5,192 encounters identified, 1,405 met the inclusion criteria. There were no significant differences between cohorts for age (P = .28) or gender (P = .43). After passage of the SMART Act, emergency department visits increased 48%, surgical intervention increased 100%, and hospital admission days increased 128%. Patients were more likely to have an OMS consult (odds ratio [OR] = 1.42; 95% confidence interval [CI], 1.11-1.81), an incision and drainage (OR = 1.48; 95% CI, 1.13-1.94), and a longer hospital admission (P = .04). The average cost per encounter increased by 20% and the total cost of care increased by $1.6 million. CONCLUSION: After limitation of dental benefits, there was an increase in the volume and severity of odontogenic infections. In addition, there was an escalated health care cost. The negative public health effects and increased economic impact of eliminating basic dental care show the importance of affordable and accessible preventative oral health care.

Oral Health Care in Rural America.

(1) Rural Americans are twice as likely to lose their adult teeth as their urban counterparts. (2) Seventy-two percent of the country is classified as rural, but is home to only 15 percent of the population (46.2 million people). (3) According to the Pew Center on the States, rural residents are more likely to use emergency departments for their oral health needs because of a lack of dental insurance and a shortage of dental providers.

'We are all scared for the baby': promoting access to dental services for refugee background women during pregnancy.

BACKGROUND: Vulnerable populations such as people with refugee backgrounds are at increased risk of poor oral health. Given that maternal characteristics play a significant role in the development of dental caries in children, antenatal care offers an opportunity to both provide information to women about the importance of maternal oral health and accessing dental care. Although pregnant women are recognised for 'priority' care under Victorian state-government policy, rarely do they attend. This study aims to describe Afghan and Sri Lankan women's knowledge and beliefs surrounding maternal oral health, barriers to accessing dental care during pregnancy, and to present the perspectives of maternity and dental service providers in relation to dental care for pregnant women. METHODS: One agency comprising both dental and maternity services formed the setting for the study. Using participatory methods that included working with bicultural community workers, focus groups were conducted with Afghan and Sri Lankan refugee background participants. Focus groups were also completed with midwives and dental service staff. Thematic analysis was applied to analyse the qualitative data. RESULTS: Four community focus groups were conducted with a total of 14 Afghan women, eight Sri Lankan women, and three Sri Lankan men. Focus groups were also conducted with 19 dental staff including clinicians and administrative staff, and with ten midwives. Four main themes were identified: perceptions of dental care during pregnancy, navigating dental services, maternal oral health literacy and potential solutions. Key findings included women and men's perception that dental treatment is unsafe during pregnancy, the lack of awareness amongst both the midwives and community members of the potential impact of poor maternal oral health and the overall lack of awareness and understanding of the 'priority of access' policy that entitles pregnant women to receive dental care cost-free. CONCLUSION: This study highlights a significant policy-to-practice gap which if not addressed has the potential to widen oral health inequalities across the life-course. Stakeholders were keen to collaborate and support action to improve the oral health of mothers and their infants with the over-riding priority being to develop inter-service relationships to promote seamless access to oral health care.

Increasing Access to Dental and Medical Care by Allowing Greater Flexibility in Scope of Practice.

In recent years, advocates for increasing access to medical and oral health care have argued for expanding the scope of practice of dentists and physicians. Although this idea may have merit, significant legal and other barriers stand in the way of allowing dentists to do more primary health care, physicians to do more oral health care, and both professions to collaborate. State practice acts, standards of care, and professional school curricula all support the historical separation between the 2 professions. Current laws do not contemplate working across professional boundaries, leaving providers who try vulnerable to legal penalties. Here we examine the legal, regulatory, and training barriers to dental and medical professionals performing services outside their traditional scope of practice.

The Changing Landscape of Health Care Coverage and Access: Comparing States' Progress in the ACA's First Year.

This analysis compares access to affordable health care across U.S. states after the first year of the Affordable Care Act's major coverage expansions. It finds that in 2014, unin­sured rates for working-age adults declined in nearly every state compared with 2013. There was at least a three-percentage-point decline in 39 states. For children, uninsured rates declined by at least two percentage points in 16 states. The share of adults who said they went without care because of costs decreased by at least two points in 21 states, while the share of at-risk adults who had not had a recent checkup declined by that same amount in 11 states. Yet there was little progress in expanding access to dental care for adults, which is not a required insurance benefit under the ACA. Wide variation in insurance coverage and access to care persists, highlighting many opportunities for states to improve.

Oral Healthcare Implications of Mass Migration.

Population movements, whether voluntary or forced, are an integral part of an increasingly globalized society and, while the health needs of migrant populations cannot be generalized, some migrants can have worse oral health outcomes compared with their host-country counterparts, with their first dental contact typically being for emergency care. Failure to provide immediately necessary treatment may be unlawful under the Human Rights Act 1998. CPD/Clinical Relevance: NHS dental services need to evolve and address the challenges inherent in caring for vulnerable migrants. Education and appropriate training needs to be developed for the dental profession in order to enable new ways of promoting intersectoral care and community engagement.

International rescue? Managing the dental tourist.

UNLABELLED: The concept of dental tourism can be considered two-fold. On one side it is a term used to describe non-UK residing patients who visit, requesting NHS dental care whilst here in the U.K. Alternatively, it also encompasses patients who travel to destinations outside their residing countries to receive care. The latter has become an ever-growing issue in the U.K.; one that warrants appropriate management and knowledge of current legislation amongst dental professionals. CLINICAL RELEVANCE: Clarity and guidance on who is eligible for care under the NHS when visiting the U.K. and who, if anyone, is ultimately responsible when treatment abroad fails.

HUMAN RIGHTS AND NIGERIAN PRISONERS--ARE PRISONERS NOT HUMANS?

In Nigeria, just like in many other parts of the world, one of the most extensively discussed issues on the public agenda today is the increase in prison population. The aims of imprisonment are protection, retribution, deterrence, reformation and vindication. Investigations revealed that the prison services have been,neglected more than any other criminal justice agency in Nigeria. For example, most of the prisons were built during the colonial era for the purpose of accommodating a small number of inmates. Human Rights are the basic guarantees for human beings to be able to achieve happiness and self-respect; consequently, in most jurisdictions, the Human Rights Act confirms that these Rights do not stop at the prison gates. However, most States fail to meet the Human Rights obligations of their prisoners. As regards to health, for example, every prison should have proper health facilities and medical staff to provide dental and psychiatric care among others. This article discusses the Nigerian Prison System and challenges, trends and the related Human Rights and Ethical issues in Nigerian prisons. Some of the unmet needs of Nigerian prisoners which include, inter alia, living in unwholesome cells, delayed trial of inmates, lack of voting rights, access to information, lack of conjugal facilities for married prisoners, poor and inadequate nutrition, poor medical care, torture, inhumane treatment and the need to protect prisoners in a changing world. The present report has policy implications for reforming prison services in Nigeria, and countries that sing from the same song sheet with Nigeria on prison services, to conform to the Fundamental Human Rights of prisoners in the 21St century.

Health and human rights a South African perspective.

General statements of basic entitlements are established as a guide for potential laws and regulations protecting human rights. Human rights are those claimed to belong to every individual regardless of nationality or position within society. The historical evolution of human rights relative to health in the Republic of South Africa is discussed.

Expanding oral care opportunities: direct access care provided by dental hygienists in the United States.

UNLABELLED: Dental hygienists expand access to oral care in the United States. BACKGROUND: Many Americans have access to oral health care in traditional dental offices however millions of Americans have unmet dental needs. For decades dental hygienists have provided opportunities for un-served and under-served Americans to receive preventive services in a variety of alternate delivery sites, and referral to licensed dentists for dental care needs. METHODS: Publications, state practice acts, state public health departments, the American Dental Hygienists' Association, and personal interviews of dental hygiene practitioners were accessed for information and statistical data. RESULTS: Dental hygienists in 36 states can legally provide direct access care. Dental hygienists are providing preventive services in a variety of settings to previously un-served and under-served Americans, with referral to dentists for dental needs. CONCLUSION: Dental hygienists have provided direct access to care in the United States for decades. The exact number of direct access providers in the United States is unknown. Limited research and anecdotal information demonstrate that direct access care has facilitated alternate entry points into the oral health systems for thousands of previously un-served and underserved Americans. Older adults, persons with special needs, children in schools, pregnant women, minority populations, rural populations, and others have benefited from the availability of many services provided by direct access dental hygienists. Legislatures and private groups are becoming increasingly aware of the impact that direct access has made on the delivery of oral health care. Many factors continue to drive the growth of direct access care. Additional research is needed to accumulate qualitative and quantitative outcome data related to direct access care provided by dental hygienists and other mid level providers of oral health services.

Breaking the cycle in Maryland: oral health policy change in the face of tragedy.

In response to the death of a young child, efforts by many partners have enabled Maryland to institute oral health reforms that ensure that low-income children remain visible and have continued access to dental services. This paper shows how proponents of oral health in Maryland used issues that were already on the oral health policy agenda to break the cycle of nonaction and become a role model for other states. Deriving from the knowledge and advice of an advisory committee, Maryland administrators and state and federal legislators, with the support of many community partners, took appropriate action to elevate the oral health agenda. Maryland continues to address oral health issues, ensuring that the policy agenda is inclusive of all its citizens.

Health care seeking among detained undocumented migrants: a cross-sectional study.

BACKGROUND: As in many European countries, access to care is decreased for undocumented migrants in the Netherlands due to legislation. Studies on the health of undocumented migrants in Europe are scarce and focus on care-seeking migrants. Not much is known on those who do not seek care. METHODS: This cross-sectional study includes both respondents who did and did not seek care, namely undocumented migrants who have been incarcerated in a detention centre while awaiting expulsion to their country of origin. A consecutive sample of all new arrivals was studied. Data were collected through structured interviews and reviews of medical records. RESULTS: Among the 224 male migrants who arrived at the detention centre between May and July 2008, 173 persons were interviewed. 122 respondents met inclusion criteria. Only half of the undocumented migrants in this study knew how to get access to medical care in the Netherlands if in need. Forty-six percent of respondents reported to have sought medical help during their stay in the Netherlands while having no health insurance (n = 57). Care was sought most frequently for injuries and dental problems. About 25% of these care seekers reported to have been denied care by a health care provider. Asian migrants were significantly less likely to seek care when compared to other ethnic groups, independent from age, chronic health problems and length of stay in the Netherlands. CONCLUSION: The study underlines the need for a better education of undocumented patients and providers concerning the opportunities for health care in the Netherlands. Moreover, there is a need to further clarify the reasons for the denial of care to undocumented patients, as well as the barriers to health care as perceived by undocumented migrants.

The patient protection and affordable care act: effects on dental care.

Health care reform has been a subject of debate long before the presidential campaign of 2008, through the presidential signing of the Patient Protection and Affordable Care Act (PPACA) on March 23, 2010, and is likely to continue as a topic of discussion well into the future. The effects of this historic reform on the delivery of healthcare and on the economy are subject to speculation. While most people are at least generally aware that access to medical care will be improved in many ways, few people, including many in the dental profession, are aware that this legislation also addresses oral health disparities and access to dental care. It is the purpose of this paper to review how dental care is currently accessed in the United States and where oral health care disparities exist, to suggest approaches to alleviating these disparities and to delineate how the changes in dental policies found in the PPACA hope to address these concerns. The main arguments of organized dentistry, both those in support of and in opposition to the PPACA, are summarized.