Letter from America: UK and US state-funded dental provision.

OBJECTIVES: Current UK and US economic conditions have re-focussed attention on the need to deliver dental care with limited finance and resources. This raises hard questions determining which services will be offered and what they should achieve to satisfy public demands and needs. We consider impending dental health reforms in the US and UK within the context of contemporary experiences to identify issues and delivery goals for the two nations. BACKGROUND: The paper provides a brief history and background of the development of social dental care models in the UK and US, highlighting some differences in state-funded delivery of dental care. SHIFTING DEMAND: From the 1950s, demand for dental treatment has increased and acquired a more complex composition growing from predominantly surgical and restorative treatment to encompass preventive care and cosmetic services. PRIORITISING CARE ACCORDING TO NEED: Despite improvements in general health and technology, inequalities in access and utilisation of dental care are still experienced, primarily by groups with low socio-economic status. DELIVERY: BALANCING RESOURCES, DEMAND AND NEED: In developing and delivering reform agendas, much can be learned from previous policy interventions. Pressures of cost, coverage, and capacity, besides demand versus need must be carefully considered and balanced to deliver quality service and value for users and taxpayers. CONCLUSIONS: Ethical and moral consideration should be given to making services needs-driven to address high treatment requirements rather than the high care demands of the worried well. This challenge brings the additional political pressure of convincing many of the voters (and subsequent complainers) that their demands may be less important than the needs of others.

Experiences of three states implementing the Medicaid health home model to address opioid use disorder-Case studies in Maryland, Rhode Island, and Vermont.

PURPOSE: The United States is facing an unprecedented opioid epidemic. The Affordable Care Act (ACA) included several provisions designed to increase care coordination in state Medicaid programs and improve outcomes for those with chronic conditions, including substance use disorders. Three states-Maryland, Rhode Island, and Vermont - adopted the ACA's optional Medicaid health home model for individuals with opioid use disorder. The model coordinates opioid use disorder treatment that features opioid agonist therapy provided at opioid treatment programs (OTPs) and Office-based Opioid Treatment (OBOT) with medical and behavioral health care and other services, including those addressing social determinants of health. This study examines state approaches to opioid health homes (OHH) and uses a retrospective analysis to identify facilitators and barriers to the program's implementation from the perspectives of multiple stakeholders. METHODS: We conducted 28 semi-structured discussions with 70 discussants across the three states, including representatives from state agencies, OHH providers (OTPs and OBOTs), Medicaid health plans, and provider associations. Discussions were recorded, transcribed, and analyzed using NVivo. In addition, we reviewed state health home applications, policies, regulatory guidance, reporting, and other available OHH materials. We adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) model as a guiding framework to examine the collected data, helping us to identify key factors affecting each stage of the OHH implementation. RESULTS: Overall, discussants reported that the OHH model was implemented successfully and was responsible for substantial improvements in patient care. Contextual factors at both the state level (e.g., legislation, funding, state leadership, program design) and provider level (OHH provider characteristics, leadership, adaptability) affected each stage of implementation of the OHH model. States took a variety of approaches in designing and implementing the model, with facilitators related to gathering stakeholder input, receiving guidance and technical assistance, and tailoring program design to build on the state's existing care coordination initiatives and provider infrastructure. The OHH model constituted a substantial change for almost all OHH providers in the study, who reported that facilitators to implementation included having goals and workplace culture that were compatible with the OHH model, and having technical support from the state or non-governmental organizations. Some of the main barriers to implementation reported by OHH providers include shortages of primary care providers, dentists, and other providers willing to accept referrals of patients with opioid use disorder; limited community resources to address social determinants of health; challenges related to state-specific program design, such as staffing requirements and reimbursement methodology; care coordination limitations due to confidentiality restrictions and technological barriers; and internal capacity of providers to adopt the new model of care. CONCLUSIONS: The OHH model appears to have the potential to effectively address the complex needs of individuals with opioid use disorder by providing whole-person care that integrates medical care, behavioral health, and social services and supports. The experiences of Maryland, Rhode Island, and Vermont can guide development and implementation of similar OHH initiatives in other states.

The Affordable Care Act and health insurance exchanges: effects on the pediatric dental benefit.

PURPOSE: To examine the relationship between state health insurance Exchange selection and pediatric dental benefit design, regulation and cost. METHODS: Medical and dental plans were analyzed across three types of state health insurance Exchanges: State-based (SB), State-partnered (SP), and Federally-facilitated (FF). Cost-analysis was completed for 10,427 insurance plans, and health policy expert interviews were conducted. One-way ANOVA compared the cost-sharing structure of stand-alone dental plans (SADP). T-test statistics compared differences in average total monthly pediatric premium costs. RESULTS: No causal relationships were identified between Exchange selection and the pediatric dental benefit's design, regulation or cost. Pediatric medical and dental coverage offered through the embedded plan design exhibited comparable average total monthly premium costs to aggregate cost estimates for the separately purchased SADP and traditional medical plan (P=0.11). Plan designs and regulatory policies demonstrated greater correlation between the SP and FF Exchanges, as compared to the SB Exchange. CONCLUSIONS: Parameters defining the pediatric dental benefit are complex and vary across states. Each state Exchange was subject to barriers in improving the quality of the pediatric dental benefit due to a lack of defined, standardized policy parameters and further legislative maturation is required.

The impact of the Medicaid/CHIP expansions on children: a synthesis of the evidence.

This article reviews findings from 38 rigorous studies published in the peer-reviewed literature of the impact of the Medicaid/Children's Health Insurance Program (CHIP) expansions on children. There is strong evidence for increases in enrollment in public programs and reductions in uninsurance following eligibility expansions. Medicaid enrollment continued to increase during the CHIP era (a "spillover effect"). Evidence for improved access to and use of services, particularly for dental care, is also very strong. There are fewer studies of health status impacts, and the evidence is mixed. There is a very wide range in the size of effects estimated in the studies reviewed because of the methods used and the populations studied. The review identifies several important research gaps on this topic, particularly the small number of studies of the effects on health status. Both research methods and findings from the child expansions can provide insights for evaluating the coming expansions for adults under the Affordable Care Act.

Teledentistry-assisted, affiliated practice for dental hygienists: an innovative oral health workforce model.

The 2010 U.S. Patient Protection and Affordable Care Act (PPACA) calls for training programs to develop mid-level dental health care providers to work in areas with underserved populations. In 2004, legislation was passed in Arizona allowing qualified dental hygienists to enter into an affiliated practice relationship with a dentist to provide oral health care services for underserved populations without general or direct supervision in public health settings. In response, the Northern Arizona University (NAU) Dental Hygiene Department developed a teledentistry-assisted, affiliated practice dental hygiene model that places a dental hygienist in the role of the mid-level practitioner as part of a digitally linked oral health care team. Utilizing current technologies, affiliated practice dental hygienists can digitally acquire and transmit diagnostic data to a distant dentist for triage, diagnosis, and patient referral in addition to providing preventive services permitted within the dental hygiene scope of practice. This article provides information about the PPACA and the Arizona affiliated practice dental hygiene model, defines teledentistry, identifies the digital equipment used in NAU's teledentistry model, give an overview of NAU's teledentistry training, describes NAU's first teledentistry clinical experience, presents statistical analyses and evaluation of NAU students' ability to acquire diagnostically efficacious digital data from remote locations, and summarizes details of remote applications of teledentistry-assisted, affiliated practice dental hygiene workforce model successes.