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Expanding Dental Insurance Coverage through Government Programs (Medicare, Medicaid)
Because oral health problems are increasingly linked to general health pathologies, there is clearly a need to consider inclusion of dental benefits under Medicare, the federal program that has largely made access to health care a reality for American retirees. In fact, despite the inclusion of dental benefits at the inception of Medicare, it now covers virtually no oral health services. For some, preventive dental care may be obtained through purchase of “Medi-gap” policies, but for many this is an unaffordable option. While much energy has been spent reforming Medicaid dental programs, most of the attention has been focused on improving dental access for children. Because the oral health needs of the elderly are vastly different than those for children, there is a great need to develop policies relevant for the oral health needs of the frail elderly, such as cost-reimbursement models for providers serving this population. Current national trends indicate a growing number of elderly living longer and retaining larger numbers of their natural teeth. Together, these phenomena indicate an increasing need for dental care into old age.
• Dental insurance coverage needs to extend past retirement into old age. It is well known that people with coverage tend to utilize more preventive services than those without. Dental insurance needs to address the reality that dental diseases increase as patients progress from functional independence to become frail and functionally dependent.
• To prevent the rapid onset of dental problems that occurs prior to the need for home health or nursing home services, Medicare should be expanded to cover dental services. Alternately, Medi-gap and private-sector retiree policies should include dental coverage.
• For the frail elderly who are poor, Medicaid needs to be expanded to cover dental services for adults in all states. Covered services need to include house call fees, gross oral cleanings, behavior management, and other services needed by frail elderly patients.
• Medicaid programs should be patterned more like private insurance.
• Medicaid reimbursements should be raised to levels closer to usual and customary levels. The American Dental Association (ADA) recommends reimbursement at the 75th percentile.
• Medicaid program administration should be simplified to reduce administrative costs, treatment delays, and provider disincentives to participation.
• Medicaid programs should be permitted to contract for special access programs on a cost-reimbursement model or modified capitation model.
• Medicaid programs should not discriminate on the basis of the age of a recipient, but rather provide benefits that are “appropriate and necessary to maintain the health of recipients.”
An overarching theme that must be considered in each aspect of training at all levels is that both didactic and hands-on experience is needed. Further, the training experience must be long enough and of appropriate intensity that trainees feel comfortable providing the care. An excellent method for getting the disciplines to work together is to have them train together, in both didactic as well as clinical settings. Interdisciplinary training in the learning environment fosters interdisciplinary collaboration in the workplace.
The most critical training needs for caregivers are that they:
• Know the importance of daily oral hygiene care to maintaining oral health
• Can use basic oral hygiene devices (toothbrush and floss) to clean someone else’s teeth
• Can provide oral hygiene services while practicing effective infection control
• Know when professional dental help is needed.
Undergraduate medical and nursing training should incorporate:
• Oral medicine for identification of common oral diseases including periodontal disease, caries, oral cancer, and various soft tissue abnormalities
• Oral pharmacology for familiarization with the adverse oral side effects of commonly used chemotherapeutic agent prescribed for chronic diseases of the elderly
• Clinical training in head and neck examination with a strong intraoral component
• Guidelines for dental referral
• Oral consequences of systemic disease and systemic consequences of oral disease including recent research findings linking oral disease to heart disease, exacerbation of lung disease, and incidence of aspiration pneumonia. In addition, continuing education in nursing and medicine should incorporate all of the same training noted above for undergraduate medical and nursing students plus provide clinical training for nurses to do the oral component of the Minimum Data Set assessment.