Dental Safety Net in Iowa

The impact of the Affordable Care Act and other delivery system changes on the oral health safety net

The Patient Protection and Affordable Care Act (ACA) and other associated payment and delivery system changes could have a profound impact on access to health care services. The University of Iowa Public Policy Center (PPC) is currently working with The Commonwealth Fund (New York, NY) to evaluate the impact of the ACA on safety net providers and payers in Iowa. The DSNI Project is studying this impact on oral health care and the oral health safety net. This project, now in its second year, is supported by a demonstration grant from the DentaQuest Foundation (Boston, MA) to investigate ACA-related changes to the dental safety net in Iowa. This project aims to identify opportunities for handling those changes.

The ultimate goal of this activity is to inform policymakers in Iowa and nationally of the dental specific issues regarding the implementation of the ACA and to develop strategies to address dental needs in the near and distant future including opportunities for public/private partnerships.

Project Description
The study investigates the challenges likely to be faced by oral health providers in managing changes associated with ACA implementation, including Medicaid expansion.  To date, this project has:

1. Examined the existing state of access to dental care in Iowa,
2. Assessed capacity of the current public dental safety net providers, and
3. Evaluated the level of private dentist participation in Medicaid and identified factors affecting their participation.

Activities that are underway will:

1. Evaluate current gaps in the safety net system,
2. Develop a primary care dental home model,
3. And explore the role that the dental profession can play within new models of service provision, including ACOs.

A National Advisory Committee for the DSNI project operates as a subcommittee to the broader Commonwealth Fund supported safety net project and provides feedback at key steps throughout this project.

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[collapsed title="Project phases in detail"]

Phase 1. Background inventory report on oral health in Iowa (Complete, click here for report)
Compiled an oral health inventory report that draws principally from available secondary data concerning information on the following in Iowa:

• Access to care and utilization of services
• Dental public health activities
• Existing workforce and identified workforce needs

Phase 2. Establish an Oral Health National Advisory Committee (Complete, see link above)
A National Advisory Committee established to provide guidance for the activities in this project. It includes statewide representation as well as national perspectives about the oral health safety net. 
 

Phase 3. Dental Medicaid survey (Complete, click here for report)
Developed and performed a written survey with all private practice primary care dentists in the state. This survey assesses:

• The level of participation in the Medicaid program and who makes this decision for their practice
• Attitudes toward the Medicaid program and Medicaid patients

Phase 4. Conjoint analysis to determine the factors affecting dentist participation in Medicaid (Complete, release pending)
As part of the written survey, dentists were invited to participate in a second on-line survey to more accurately differentiate factors that affect dentist participation in Medicaid. This survey involved a series of scenarios to identify situations in which dentists would be willing to accept Medicaid patients in their practices.

Phase 5. Capacity of Community Health Center dental clinics (Complete, release pending)
Through a written survey, the existing capacity of dental clinics in the Community Health Centers (CHCs) in Iowa was evaluated. This assessment included:

• Current physical facilities, number of providers and numbers of patients seen
• Barriers to expanding capacity or efficiency
• Interest and opportunities for growth in the future

Phase 6. Policy development and recommendations (currently underway)
Through discussions with the National Oral Health Advisory Committee and the State Safety Net Advisory Group, policy recommendations will be developed regarding ways to improve the oral health safety net and potentially increase public/private collaborations. Next steps for implementing the policy recommendations will also be discussed as well as ideas for future grant funding to continue these ideas toward the implementation stage where appropriate.

This project is designed to provide the information that will allow oral health policymakers and other stakeholders to have constructive deliberations and develop policy recommendations to improve access to oral health care services for vulnerable populations and the efficiency and effectiveness of the dental safety net. Both the methodologies developed through this project and the results of these analyses will be of interest to those in other states who are struggling with these same issues.

Phase 7. Development of the primary care dental home (PCDH) model (currently underway)
Health services integration, from both financing and service provision perspectives, is one of the major goals of the ACA.  This is playing out in the proliferation of Accountable Care Organizations (ACOs) and other models that coordinate health services, particularly for patients who suffer from multiple chronic illnesses.  There are many opportunities to connect the dental home with the coordinated practice of medicine.  However, there is no standard definition of a dental home nor are there guidelines for applying that concept into the dental practice.  Therefore, this phase will formulate the concept of the “primary care dental home” and create guidelines for how it can be applied in a practice setting.  To achieve these aims, we will compile background information from medicine, dentistry, and the ACA, which will inform and guide a group input process with national experts.

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