Oral Health Services Consumer Engagement - June 2021
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Oral Health Services
Consumer Engagement
Research Report
June 2021
2021 RESEARCH REPORT 1
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ACKNOWLEDGEMENTS
The Florida Institute for Health Innovation would like to express sincere gratitude to members of the Flor-
ida Oral Health Alliance, the statewide Florida Oral Health Alignment Network, and the Florida Oral Health
Consumer Advisory Council for their commitment to improving oral health for Florida’s most vulnerable
children and for providing oral health statistics and resources that contributed to the foundation of this
report. The Institute would also like to thank our project staff, interns, and volunteers for assisting with
data collection, conducting research and analysis and establishing the partnerships that made this work
possible. We are tremendously grateful to our partners who helped connect us to the families they serve
through securing participation in our surveys and focus groups. We are also deeply grateful to the many
families throughout the state who volunteered their time to share their personal stories through focus
groups and surveys; we appreciate your willingness to participate and your candid responses that inform
us of the consumer experience. Finally, we would like to extend our deepest thanks to the DentaQuest
Partnership for Oral Health Advancement (formerly the DentaQuest Foundation) for providing the oppor-
tunity and support to develop this important study.
Partner organizations include:
ACCESS Florida
ACORN Dental Clinic/Alachua Oral Health Coalition
Agency for Persons with Disabilities (APD)
Bridges of Boynton Beach
Bridges of West Palm Beach
Camillus House & Health
Catalyst Miami
Children’s Trust
Early Learning Coalition of Orange County
Early Learning Coalition of Flagler and Volusia County
Florida Department of Children and Families
Florida Department of Health
Goodwill
Iglesia Oasis de Amor
Jack & Jill Children’s Center
Jessie Trice Community Health Center
Metropolitan Ministries
Orlando Day Nursery
St. Petersburg Free Clinic
The Children’s Trust
The Health Planning Council of Southwest Florida/Early Steps
2 2021 RESEARCH REPORT 2021 RESEARCH REPORT 3
Florida Institute for
Student Interns TABLE OF CONTENTS
Health Innovation
Joseph West, ScD Christine Castiglione
Chief Executive Officer University of Miami, Intern
Executive Summary�������������������������������������������������������������������������������������������������������������������������������� 6
Kristin Palbicke Garces, MPH Martha Caceres Background�����������������������������������������������������������������������������������������������������������������������������������������������11
Chief Operating Officer Florida International University, Intern
Oral Health in the United States�������������������������������������������������������������������������������������������������������������� 11
Danielle Lewald Ruby Silva
Existing Health Conditions������������������������������������������������������������������������������������������������������������������������� 13
Oral Health Alliance Florida International University, Intern
Katelyn McGlynn, MPH Monica Karas The State of Children’s Oral Health in Florida �������������������������������������������������������������������������������������� 14
Consumer Engagement Florida International University, Volunteer Legal Implications Surrounding Oral Health in Florida ���������������������������������������������������������������������� 17
Azam Masood, MPH Amanda del Risco
Oral Health Consumer Engagement Pilot (2014)���������������������������������������������������������������������������������� 20
Oral Health Alliance Florida International University, Volunteer
Fay Glasgow Gabriela Roque Perez Consumer Engagement Research: 2015-17 ������������������������������������������������������������������������������������ 21
Executive Assistant Florida International University, Volunteer Surveys ���������������������������������������������������������������������������������������������������������������������������������������������������������� 22
Mary Robbins Daniela Giraldo Methodology��������������������������������������������������������������������������������������������������������������������������������������������������22
Research Consultant, PhD Student, University of Florida International University, Volunteer
Analysis and Results �������������������������������������������������������������������������������������������������������������������������������������23
California, Los Angeles Elisa Carbonell
Discussion ������������������������������������������������������������������������������������������������������������������������������������������������������26
Christine Kovach Hom, LCSW Florida International University, Volunteer
Oral Health Alliance Focus Groups ����������������������������������������������������������������������������������������������������������������������������������������������� 28
Elizabeth Henry, MPH Methodology��������������������������������������������������������������������������������������������������������������������������������������������������28
Program Manager Contributors Analysis and Results �������������������������������������������������������������������������������������������������������������������������������������29
Roderick King, MD, MPH
Discussion ������������������������������������������������������������������������������������������������������������������������������������������������������34
Assistant Dean for Public Health Education and
Ellen Jones, MD Consumer Experience and Policy: Rapid Health Impact Assessment���������������������������������38
Director, MD/MPH Program, University of Miami
Mississippi Public Health Institute, Former
Miller School of Medicine Alignment Efforts: Consumer Engagement Impact, 2017-20 ��������������������������������������������������50
Executive Director
Tara Zolnikov Opportunities to Shape the Consumer Experience and Oral Health Landscape: 2021
Associate Professor, National University and Beyond ��������������������������������������������������������������������������������������������������������������������������������������������� 51
Camilo Mejía I. STATE SURGEON GENERAL RECOMMENDATIONS �������������������������������������������������������������������������������51
Catalyst Miami, Networks Director II. AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA) RECOMMENDATIONS ������������������������������56
Scott Darius
III. SOCIAL SERVICE AND ORAL HEALTH AGENCIES����������������������������������������������������������������������������������62
Florida Voices for Health, Executive Director
IV. BEST PRACTICES FOR REPLICATION STATEWIDE���������������������������������������������������������������������������������66
Deborah Foote, MPA
Oral Health Florida, (Former) Managing Director References �����������������������������������������������������������������������������������������������������������������������������������������������70
Carrie Hepburn Appendices����������������������������������������������������������������������������������������������������������������������������������������������� 81
Tampa Bay Healthcare Collaborative, Chief
Executive Officer
4 2021 RESEARCH REPORT 2021 RESEARCH REPORT 5
Consumer Engagement Research: for parents to consistently seek care for their
Executive Summary 2015-17 children.
Linguistic and cultural barriers exist for
The Institute used both qualitative and quantita- minority populations when accessing dental
The purpose of this report is to comprehensive- Oral Health in America detailed the link between services.
tive research methods and public health evalua-
ly examine the current realities of children’s oral oral health and overall health in 2000. Low-income Cost, lack of dental insurance, and issues
tion specialists to better understand opportuni-
health in Florida in order to inform government children face increased difficulties accessing oral navigating the oral health care system are the
ties and obstacles that exist for families accessing
leaders, policymakers, and other stakeholders health, especially children who are Medicaid and most common reasons parents have trouble
dental health services. The research focuses on
working in public health and dental health. The CHIP beneficiaries (GAO, 2013). Research shows accessing dental care for their children.
families and individuals enrolled in Medicaid-eli-
report is intended to be used as a tool to guide that poor oral health can lead to a variety of ad-
gible programs in rural and urban sites in Florida.
the mission of organizations and agencies that verse health outcomes including cardiovascular
work to evaluate and improve oral health care disease, diabetes, poor mental health and stroke.
Through focus groups (n = 39) and surveys (n = Focus Groups
342) with Medicaid-eligible families, Institute staff
services and delivery in the state of Florida. Giv-
assessed and analyzed the current state of dental The focus group results outline findings that
en the current legal status of oral healthcare, this Oral Health in Florida health in urban and rural Florida. present opportunities and underscore actions re-
report is well positioned to provide stakeholders,
quired, by topic area.
specifically the Agency for Health Care Adminis- Similar to children across the United States, Med-
Surveys
tration (AHCA), the Department of Health and or- icaid-eligible children in Florida face numerous
Knowledge and Care
ganizations in the field with information to guide obstacles obtaining dental care. The KidCare Eval-
The survey results illuminate a number of import- As the data above suggest, a range of behav-
policies and practices and to offer insight on how uation Final Report (Brishke et al., 2020) revealed
ant messages about parent/child experiences iors and attitudes exist within parents and
to prioritize and address consumer needs. that in Florida only 31.8 percent of 6–9-year-old
with the oral health care system in Florida. their understanding of their children’s dental
children at elevated caries risk received dental
health. The following key themes came from
sealants in CY 2019. Florida remains significant-
Positive Findings the focus group analysis:
Oral Health in the U.S. ly behind national oral health rankings, with 47.4
Having a regular dental home for their Parents understand that oral health is
percent of U.S. Medicaid-eligible children aged
child does not affect parents/caregivers per- important for many reasons.
Since 1950, the United States has led incredible 0-20 receiving any dental service compared to
ceptions of their child’s dental and overall Culture and language shape consumers’
work in treating oral health as a public health ne- only 38.8 percent in Florida, and only 35.5 percent
health. experience and knowledge of dental health.
cessity. Most gains have come as a result of ef- of Medicaid-eligible children receiving any pre-
Overall, parents/caregivers with provid- Dental health needs to be normalized for
fective prevention and treatment efforts such as ventive dental service, compared to the nation-
ers were happy with the care their child re- parents and children.
community water fluoridation and school-based al average of 43.9 percent (CMS, 2019). Findings
ceived. Communication and experience in den-
dental sealant programs. Community water flu- from the survey of third grade students from 42
tal health needs improvement.
oridation benefits 73 percent of Americans who Florida elementary schools, showed that 45.5 per-
Opportunities Transparency of processes.
get water through public systems (Centers for cent had experienced caries and 25.1 percent had
Parents receive oral health care informa-
Disease Control and Prevention [CDC], 2020c) untreated decay with the prevalence being high-
tion from their child’s primary care doctor. Accessibility and Barriers to Oral Health
and dental sealants can prevent up to 80 percent est for non-Hispanic Black children (34.6%) and
Parents understand oral health care is There are a number of structural barriers
of tooth decay. Despite this progress, 66.7 million for children without any dental insurance (32.8%).
important. that prevent Medicaid-eligible families from
Americans do not have dental coverage or access Research shows that these disparities are strong-
Parent’s dental care utilization affects accessing dental health services. However,
to dental services (National Association of Dental ly associated with race, class, gender, and ethnici-
their child’s dental home and health insur- there was also data indicating some families’
Plans [NADP], n.d.) and less than half of children ty. This report supports this finding and also high-
ance status. positive experiences in dental offices. Data
ages 6 to 11 years have dental sealants (Griffin et lights the importance of location, race, language,
from the focus groups reveal dental health
al., 2016; CDC, 2021e). Furthermore, dental car- and culture in communities that lack access to
Action Required barriers and accessibilities related to the fol-
ies, or cavities, have remained the most common preventive dental health services.
Parent’s dental care utilization affects lowing areas:
chronic disease of children age 6-11 and 12-19
their child’s dental home status.
since the Surgeon General’s first-ever report on
Trust in dental care providers is essential Cost, appointment wait-times, and out-
6 2021 RESEARCH REPORT 2021 RESEARCH REPORT 7
dated or inconsistent misinformation are cess for Medicaid recipients. The assessment fo- training to improve Early Childhood Caries
the most common reasons parents have cuses on reporting the potential, and sometimes (ECC) management and access to preventive Social Services and Oral Health Agencies
trouble accessing dental care for their chil- unintended, effects of policies and programs on oral health services in vulnerable popula- Mobilize a network of oral health con-
dren. the health of the population and reviews distribu- tions. sumer advocates to communicate barriers to
Streamline administration and com- tion of those effects within the population; out- Utilize the American Dental Association and inequities in dental care to inform policy.
munication about services. lines the health impacts of allocating resources Foundation’s Tiny Smiles: Give Kids A Smile Community-based organizations should
Transportation and Distance. for access to oral hygiene and health and exam- Program Tools and Resources. link clients to both dental homes and health-
Medicaid needs to increase accessibili- ines how oral health barriers and limited access Fund and expand the Dental Student care services.
ty to oral health care services. to dental care can have severe impacts on the Loan Repayment Program and promote par- Educate the public and elected officials
Professionalism and quality care. well-being and general health of millions of Flo- ticipation in eligible Professional Postgradu- about health outcomes and costs associated
ridians; and describes policy changes from 2018 ate Dental training. with oral health and emphasize the health
to present that will impact residents throughout risks associated with poor oral health, espe-
Access Information
the state. Understanding the passing and failing Agency of Health Care Administration cially for emergency dental care.
Parents rely on referrals and word of mouth
of proposed legislation will be of value to policy- (AHCA) Recommendations Advocate Medicaid expansion in the
to find dentists and other information on
makers, stakeholders across governmental, med- Expand the scope of practice for Dental state to increase the pool of eligible recipi-
oral health in their communities. Technol-
ical, and community partnerships, and Medicaid Hygienists. ents.
ogy (radio, TV, and the internet) and those
recipients. Develop/update a comprehensive, us- Consider partnering with local dental
who have access to it is also a theme that
er-friendly online oral health resource guide hygiene programs for workforce interven-
came up in focus groups. In order to ensure
that allows consumers to search for specific tion models.
access to information on dentists, pam-
Opportunities to Shape the services based on zip code, health plan and Engage in community water fluoridation
phlets, texts, and other media need to be
Consumer Experience and area of need. campaigns and advocacy work.
culturally and linguistically appropriate and
Oral Health Landscape Institute a toll-free number for both Conduct continuous public health eco-
all methods of dissemination e.g. through
Medicaid beneficiaries and dental providers nomic evaluations and analysis at communi-
doctors and schools explored.
The recommendations below represent evi- to improve dental appointment compliance. ty and state levels to demonstrate cost-sav-
dence-based policies and programs that can in- Establish a Medicaid dental advisory ings and inform policy decisions.
Parents find oral health information
form state, municipal, and Medicaid planning to committee.
via a variety of sources.
improve oral health care services and delivery in Expand implementation and mandate Best Practices for Replication Statewide
Mailings are the best way to get infor-
usage of an integrated electronic health re- Expand the usage of medical/dental
mation to families. the state of Florida.
cord system statewide within Florida’s Med- vans as a means of removing barriers to ac-
Provide free or low-cost communi-
icaid Program. cess.
ty-based services. State Surgeon General Recommendations
Consider broadening the dental work- Implement a Virtual Dental Home mod-
Co-locate medical and dental services
force to include dental therapists to improve el in conjunction with tele-dentistry.
to increase the provision of preventive oral
community-level outcomes. Conduct and promote interactive oral
Consumer Experience and Policy: health services.
Find ways to motivate oral health pro- health education programs designed for and
Rapid Health Impact Assessment Provide cultural competency training for
viders and reduce obstacles to increase par- by Spanish/Haitian speaking families and led
medical and dental providers.
ticipation in Medicaid. by designated community health educators.
To comprehensively outline actions taken by the Restrict papoose utilization.
Establish a First Dental Home Initiative, Invest in case management and care fa-
state or policies under consideration to address Contract with a research organization
modeled after Texas, to provide training to cilitation to encourage partnerships between
the findings above, a rapid Health Impact Assess- to conduct a statewide oral health needs as-
pediatric dentists about establishing a dental medical and dental homes.
ment (HIA) was conducted. The HIA catalogues sessment to inform an updated statewide
home for children who are at high caries risk. Provide oral health education and treat-
and assesses the oral health policy landscape of oral health plan.
Create programs for integration of oral ment to expectant mothers in high-risk pop-
Florida to determine areas of growth and weak- Utilize existing monitoring systems to
health services with primary care. ulations.
ness, specifically as they relate to oral health ac- build statewide oral health capacity.
Expand the dental hygienist scope of
Provide interprofessional education and
work to provide oral health services and re-
8 2021 RESEARCH REPORT 2021 RESEARCH REPORT 9
ferrals.
Pilot Dental Care Coordinator interventions.
For helpful framing, we divided the report into the
following sections: (1) background on oral health
and children’s oral health in Florida, (2) results
from our 2017 study, (3) policy implications for
consumer experience via health impact assess-
ment, (4) efforts for collective impact, and (5) fu-
ture recommendations, policy design, and legisla-
tive funding to support oral health outcomes for
Background
the children of Florida.
health in 2000 (HHS, 2000). Poor oral health that
Oral Health in the United States
results from a lack of regular treatment can cause
pain and tooth loss, impede productivity, and po-
It is well established that the health of the teeth
tentially exacerbate many other chronic health
and the mouth is central to a person’s overall
conditions.
“
health and well-being. Yet, presently in the United
States, children remain to be at an increased risk
for oral and craniofacial diseases (US Department
of Health and Human Services [HHS], 2000). In
Dental caries, or cavities,
Healthy People 2020, a nationwide agenda pro-
moting health in the United States, oral health in
children and adolescents was highlighted as one
of the primary targets for improving overall popu-
lation health. Similarly, one of the main objectives
of Healthy People 2030 is to increase the per-
centage of children, adolescents, and adults who
have also remained the
most common chronic dis-
ease of children age 6-11
and 12-19 since the Surgeon
“
General’s first-ever report on Oral
Health in America detailed the
received oral health care in the past year (CDC, link between oral health and over-
2020a). all health in 2000 (HHS, 2000).
Public health measures and goals surrounding
children’s oral health reflect the importance of
this subject for state and federal programs and APPROX.
66.7 M
budgets. Dental caries (tooth decay) is one of the
most common chronic health problems in the
United States, impacting more than 90 percent of
U.S. adults (CDC, 2016) with 1 in 4 of those adults
suffering from untreated dental caries (CDC, Americans do not have
2021e). Dental caries, or cavities, have also re- dental coverage
mained the most common chronic disease of chil-
dren age 6-11 and 12-19 since the Surgeon Gen-
While the United States continues to make prog-
eral’s first-ever report on Oral Health in America
ress in improving oral health through enhanced
detailed the link between oral health and overall
preventive care and services, many Americans
10 2021 RESEARCH REPORT 2021 RESEARCH REPORT 11
dren and their access to preventive dental health
saves communities
United States Spent Every The effectiveness of fluoride varnish in prevent- care.
$26.9 M
anywhere from
ing caries has similarly been reviewed, however
$1
$1.10 research suggests that the infrequency of the vis-
its to receive the varnish may be limited in reach
on child and adolescent
to $135 and long-term impact (Milgrom and Cunha-Cruz,
2017). The application of fluoride varnish to teeth
invested in water in dental treatment
oral health. fluoridation costs aids in tooth remineralization and helps prevent
cavities by disrupting bacterial activity in the Poor oral health
mouth. A systematic review (Marinho et al., 2013) can lead to a
lack access to preventive services. As of 2018, ap- are shown to promote good oral health outcomes conducted in the United Kingdom compared the variety of adverse
proximately 66.7 million Americans do not have and prevent tooth decay. Community water fluo- effectiveness of fluoride varnish in preventing health outcomes:
dental coverage and many are less likely to use ridation is the most effective way to deliver flu- caries in children and adolescents. The findings
preventive dental services due to out-of-pocket oride to the entirety of the full community pop- showed an average of 43 percent reduction in de- > Cardiovascular disease
costs (NADP, n.d.). In 2013, the United State spent ulation and evidence shows it can prevent tooth cayed, missing and filled tooth surfaces (DMFT) in > Diabetes
$26.9 billion on child and adolescent oral health. decay by 18-40 percent (CDC, 1999). Additionally, permanent teeth, and a 37 percent reduction in > Dental caries
This exceeds combined expenditures on asthma, according to CDC (2020c), every $1 invested in DMFT in primary teeth. Fluoride varnish has also
> Poor mental health
upper respiratory tract infection, other infectious water fluoridation saves communities anywhere been found effective in preventing early child-
> Stroke
diseases, and anxiety (Bui et al., 2017). The NADP from $1.10 to $135 dollars in dental treatment hood caries, though not to the degree of prevent-
notes that individuals without dental benefits are costs. Economic modeling suggests that if unfluo- ing cavities in young permanent teeth. The appli-
67 percent more likely to have heart disease, 50 ridated communities with populations of 1,000 or cation of fluoride varnish is recommended as a
percent more likely to have osteoporosis, and more received fluoridation, they would save “$2.5 best practice by the American Academy of Pediat-
29 percent more likely to have diabetes. Fur- billion in costs related to dental caries” annually rics (AAP) and American Dental Association (ADA)
thermore, disparities in access and treatment in (O’Connell et al., 2016). School-based dental seal- (Marinho et al., 2013; Twetman & Dhar, 2015; Existing Health Conditions
oral health care are most prominent in vulnera- ant programs, equally effective, focus on sealing ADA, 2006; AAP, 2014). Children at an increased
ble populations. According to the Government the chewing surfaces of permanent molar teeth. risk for tooth decay (children that don’t have ac- Poor oral health can lead to a variety of adverse
Accountability Office (GAO) (2008), low-income This practice usually targets schools that serve cess to preventative care or miss regular dental health outcomes, including cardiovascular dis-
children face increased difficulties accessing oral children from low-income families. Dental seal- visits) and those that attend regular dental visits ease and diabetes (Mayo Clinic, 2019). Data from
health care and in their 2013 statement, GAO ants can prevent up to 80 percent of tooth decay stand to benefit the most from fluoride varnish. the National Health and Nutrition Examination
noted that children who were Medicaid and CHIP in the treated teeth but less than half of children Survey showed an association between poor oral
beneficiaries visited the dentist less often than ages 6 to 11 years have dental sealants (Griffin et As research suggests, a combination of individ- health and mental health that may adversely im-
privately insured children (GAO, 2013). Studies al., 2016; CDC, 2021e). ual efforts (e.g., consumer engagement educa- pact day-to-day activities (O’Neil et al., 2014). Evi-
!
have found that often these disparities can man- tion), institutional efforts (e.g., supporting Med- dence of the link between oral health and adverse
ifest as short-term maladies such as tooth pain, icaid-eligible families to access preventive dental health outcomes is as follows:
or in long-term conditions, that further affect the services), and public health efforts (e.g., commu-
child socially, economically, developmentally and
their overall health.
Two specific health interventions have impact-
ed oral health outcomes for communities across
race and socioeconomic strata over the last 75
years: community water fluoridation and school-
Dental sealants can pre-
vent up to 80 percent of
tooth decay in the treated
teeth but less than half of
children ages 6 to 11 years
! nity water fluoridation) are all necessary to pre-
vent dental caries in children as well as avert the
long-term costs of poor health outcomes. While
measuring the short and long-term impacts of (1)
individual efforts; (2) institutional efforts; and (3)
public health efforts is difficult, it is needed in or-
der to move forward with designing cost-effective
Cardiovascular Disease: Oral health and heart
disease are connected by the spread of bacte-
ria from the mouth to other parts of the body
through the bloodstream. When oral bacteria
reach the heart, they can attach themselves to
any damaged area and cause inflammation. Ac-
cording to Mayo Clinic (2019), this can result in
have dental sealants. illnesses such as endocarditis, an infection of the
based dental sealant programs. These programs policies that reach Florida’s most vulnerable chil-
12 2021 RESEARCH REPORT 2021 RESEARCH REPORT 13
inner lining of the heart, clogged arteries and n.d.) demonstrated that nearly two-thirds of re- greatly affect their scholastic outcomes; oral pain
$1.8 M
stroke. In 2019, Florida faced the second-highest spondents who had depression reported having is also a leading cause of chronic school absen-
number of heart disease-related deaths (47,144) a toothache in the last year. Additionally, half of teeism for young students (Attendance Works,
in the country (CDC, 2021d). those with depression rated their teeth condition 2015). Among school-age children, tooth decay
as fair or poor. According to Delta Dental (n.d.), is the most common chronic disease and is five
Diabetes: A growing body of research is begin- this is due to the behavioral effects of stress, de- times more prevalent than asthma. According (3 in 7) of Florida’s 4.2 million
ning to demonstrate that gum disease and dia- pression, and anxiety. Individuals suffering from to a recent survey of third grade students from children are covered by
betes are inextricably linked to one another. Ac- mental illness are less likely to keep up with rou- 42 Florida elementary schools, 45.5 percent had Medicaid.
cording to the American Diabetes Association tine oral health or visit the dentist (Oral Health experienced caries and 25.1 percent had untreat-
(n.d.), not only are people with diabetes more Foundation, n.d.). Furthermore, depression can ed decay with the prevalence being highest for
lion children under the age of 18 and of these chil-
susceptible to serious gum disease, but serious raise one’s cortisol levels weakening the immune non-Hispanic Black children (34.6%) and for chil-
dren, 1.8 million (3 in 7) are covered by Medicaid,
gum disease may have the potential to affect system and leaving one susceptible to inflam- dren without any dental insurance (32.8%). Addi-
according to data collected by the Kaiser Family
blood glucose control and contribute to the pro- mation and gum disease (Delta Dental, n.d.). In tionally, 20.6 percent needed early care and 3.0
Foundation (KFF) (2019). Florida remains below
gression of diabetes. The Journal of the American Florida, over 660,000 adults and 181,000 children percent needed urgent care (Saint-Hillien & Hol-
the national average for U.S. dentists that partic-
Dental Association published a study that sug- live with bipolar disorder, severe depression or icky, 2018). These statistics highlight the value of
ipate in Medicaid or Children’s Health Insurance
gested oral health care providers can improve the schizophrenia, and nearly half the population preventive dental care and the need to treat den-
Program (CHIP) for child dental services. Nation-
overall health outcomes of patients with diabetes will struggle with less devastating forms at some tal caries at a young age. Dental sealants can pre-
ally, 43 percent of dentists participate in Medicaid
(Lamster et al., 2008). The literature the authors point in their lives (Santich & Kunerth, 2014). Yet, vent up to 80 percent of tooth decay, however, ac-
or CHIP compared to 29.7 percent in Florida (ADA
examined supported that periodontitis, or inflam- according to a 2017 report published by Mental cording to the KidCare Evaluation Final Report, in
Health Policy Institute [HPI], 2020). The Florida
mation of the gums, is a complication of diabetes. Illness Policy Organization, Florida ranks just 41st Florida only 31.8 percent of 6-9 year-old children
Department of Health (FDOH) (Traul, 2020) 2017-
The evidence also indicated that periodontitis is a in the percentage of total state expenditures al- at elevated caries risk received dental sealants in
2018 workforce survey revealed that majority of
risk factor for poor glycemic control and the de- located to mental illness, spending 1.1 percent CY 2019, and only 40.5 percent of eligible enroll-
the respondents (78.2%) indicated that they were
velopment of other clinical complications of dia- (Jaffe & Torrey, 2017). ees 1-20 years of age received preventive dental
not enrolled as a Medicaid provider. The survey
betes. Furthermore, patients with long-standing, services. Florida KidCare is the umbrella program
results also found that dentists cited “inadequate
poorly controlled diabetes are at risk of develop- Stroke: Stroke and periodontal disease share a for Florida’s Medicaid and CHIP programs (Brishke
reimbursement” as the main reason for not en-
ing oral candidiasis, more commonly known as commonality in the form of vascular inflamma- et al., 2020).
rolling in Medicaid or accepting new Medicaid
thrush (Lamster et al., 2008). tion. Beck et al. (2008) found that older adults
patients (71.9%), followed by “too much paper-
who had higher proportions of four types of gum Florida has a population of approximately 4.2 mil-
work” (40.9%), and “frequent changes in Florida
Dental Caries: Untreated dental caries are one disease-causing bacteria also had thicker carotid
Medicaid rules and policies” (32.3%). Of actively
45.5%
of the most common childhood diseases, and arteries, which is a predictor of stroke and heart
practicing dentists in Florida, 59.3 percent report
among the most easily avoidable with regular attack. Furthermore, Renvert et al. (2006) found
performing any volunteer services over the last
preventive care. By age 8, more than half (52%) of that people with acute coronary syndrome had
24 months to provide access to dental care for
children have had a cavity in their primary teeth higher levels of oral bacteria. The study addition- of surveyed third graders at 42 elementary
schools in Florida had caries with Floridians in need. Approximately 16 percent of
and among adolescents ages 12 to 19, 57 percent ally indicated that there may be an association
25% of those being untreated these dentists indicated that they had provided
have had a cavity in their permanent teeth (CDC, between premature tooth loss and stroke occur-
at least 25 hours of volunteer services within the
2020d). Parents miss on average 2.5 days from rence.
Prevalence highest among: last 24 months, with 6.6 percent reporting volun-
work per year due to their children’s dental prob-
teering between 17-24 hours, 13 percent report-
34.5% 32.8%
lems (Seirawan et al., 2012). This amount to an The State of Children’s Oral Health in Florida
ing between 9-16 hours, and 24 percent reporting
estimated 34 million school hours lost each year
providing 1-8 hours of volunteer services. Many
because of unplanned dental care (CDC, 2020d). Similar to children across the United States, Med- Non-Hispanic Children without any
Black children dental insurance of these volunteers participate in a single-day,
icaid-eligible children in Florida face numerous
large-scale initiatives to provide temporary relief
Mental Health: Data from the National Health obstacles obtaining dental care. Oral pain can
and are not enough to cover Florida’s vulnera-
and Nutrition Examination Survey (Delta Dental, inhibit a child’s well-being, confidence and can
14 2021 RESEARCH REPORT 2021 RESEARCH REPORT 15
ble populations’ dental needs. Additionally, it is outcomes when compared to the rest of the na- cade, despite hospitals not having trained staff
important to note that these actions are derived tion. For example, approximately 23 percent of or facilities that offer dental services (ADA, 2015). In 2019, Florida hospitals
from dentists’ goodwill to help Floridians with Florida special health care needs (SHCN) children The use of ERs for dental services in Florida in- billed more than
$630 M
less access, rather than from a consumer-based, and adolescents did not have a preventative den- creased by 56 percent between 2005 and 2014
systems response. Though these humanitarian tal visit in the past year compared to 14.1 percent with visits exceeding 163,900 per year. (Tomar et
efforts offered by Florida’s providers do serve as nationally (Holicky, 2016). In 2018, Toothbrush.org al., 2016). Florida spent an estimated $234 million
additional support, Florida cannot rely on volun- conducted a study that ranked Florida 43rd out of on dental-related ER visits annually between the
teer dentists to provide services and instead must all 50 states in overall oral health wellness, 49th respective years. Additionally, the study found
for preventable ER visits and
address the underlying issues of poor oral health for the number of children with a dentist visit, and that less than one third of those dental-related ER
hospital admissions stemming
access and delivery. 48th for worst oral health condition (Toothbrush. visits resulted in care other than evaluation and
from preventable oral health
org, 2018). According to the Centers for Medicare diagnosis. Medicaid was the primary payer for
Research shows that Florida’s most vulnerable and Medicaid Services (CMS, 2019) Florida re- 38 percent of dental-related ER patients, follow
issues
children continue to experience poor oral health mained significantly behind national oral health by self-pay (38%). In 2019, Florida hospitals billed
40%
rankings, with 47.4 percent of U.S. Medicaid-eli- more than $630 million for preventable ER vis-
Dentist participation in Medicaid/CHIP: gible children aged 0-20 receiving any dental ser- its and hospital admissions stemming from pre-
Medicaid
vice compared to only 38.8 percent in Florida, and ventable oral health issues and Medicaid paid for paid for
43% 29.7%
only 35.5 percent of Medicaid-eligible children re- nearly 40% of the visits (Floridians for Dental Ac-
-Vs-
ceiving any preventive dental service, compared cess, n.d.). These visits could have been prevent-
nearly of the visits
Nationally in Florida to the national average of 43.9 percent. ed by a trip to a dental provider. Lack of Medicaid
coverage for adult dental services and low provid-
Furthermore, poor oral health can have an eco- er participation as results of low reimbursement
services at all; furthermore, a reported total of 75
Dentists in Florida report the following rea- nomic impact. The number of ER visits in US for rates are contributing to increased lack of access
sons for not participating in Medicaid/CHIP: percent of Medicaid-enrolled children in Florida
dental pain has nearly doubled over the past de- to dental care and costly ER visits.
did not receive a dental examination (The Public
Interest Law Center, n.d. - a).
Legal Implications Surrounding Oral Health in
71.9% Florida
As a result of the lawsuit, in December of 2014,
Inadequate the federal court ruled that the Florida Medicaid
reimbursement
Florida is Ranked In 2005, the Public Interest Law Center, together
with the Fort Lauderdale law firm of Boies, Schiller
program was not providing eligible children with
medical and dental care as required by federal
and Flexner, filed a class action lawsuit on behalf
rd
43
law. The Court found that approximately one-
out of all 50 states of the Florida Chapter of the American Academy of
40.9%Too much
in overall oral
health wellness
Pediatrics, the Florida Academy of Pediatric Den-
tistry, and five Florida families reliant on Medicaid
third of Medicaid-eligible children in Florida were
not receiving the preventive medical care they
were required to receive, and that the children
paperwork for their children’s health care. The suit contend-
who did receive care traveled to other areas of the
th
49
for the number of
ed the state Medicaid program was violating fed-
state and/or waited several months to obtain ba-
children with a eral law by operating a health system for the poor
dentist visit sic preventive care. For dental care, the numbers
that sets reimbursement rates too low to main-
32.3% tain enough providers in the program. According
to the lawsuit, state health reports from the fiscal
were worse, as 79 percent of Medicaid-enrolled
children did not receive any preventive service at
Frequent changes
th
48
in Florida Medicaid all (The Public Interest Law Center, n.d. - b). The
for worst oral year of 2004 discovered that 44 percent of eligible
rules and policies Florida Medicaid program was found to violate
health condition children in Florida received no health care check-
federal law by improper terminations of eligibility
ups and that more than 500,000 Medicaid-en-
for children, switching children from one provid-
rolled children received no preventive health care
16 2021 RESEARCH REPORT 2021 RESEARCH REPORT 17
er to another without their parent’s knowledge, port was released, the information was not avail-
Table 1: FL medicaid dental services and dentist rate increases by year.
and failure to provide required outreach to in- able on AHCA’s website. Attempts were made to
form eligible individuals of Medicaid services. This reach the Public Records Coordination Office at Dentist Rate Increases MCO Rate Increases
Year FL Medicaid Dental Services
(fee-for-service) from Medicaid
failure led to life-threatening delays in the provi- AHCA and the Office of General Counsel, without
sion of medical and dental care and contributed response. This highlights that accountability and 2011 No Yes
to the overwhelming bureaucratic barriers faced transparency are essential as we work together 2012 Yes Yes
by low-income children and their families. In re- as a state committed to improving our oral health
2013 • Managed Medical Assistance No Yes
gard to both medical and dental care, the Court statistics in children. (MMA) plan includes dental services.
concluded that the low reimbursement rates es- • Fee-for-service dental services.
tablished by Florida state officials were a signifi- According to Keiser Family Foundation (n.d.), Flor-
2014 No Yes
cant factor in why parents of Medicaid-enrolled ida has not increased its Medicaid dentist reim-
children were experiencing systemic failures such bursement rates since 2012. Beginning in 2013, 2015 No Yes
as delays in obtaining preventive dental care as Medicaid dental services in Florida were offered 2016 Dental services “carved- No Yes
discussed above. The Court held that an increase both on a fee-for-service basis and though man- out” from MMA plan.
in Medicaid reimbursement rates would result in aged care plan, however, in 2016 dental services
2017 No Yes
a significant increase in provider participation in were “carved-out” from Managed Medical Assis-
the program and therefore an increase in access tance plan and in 2019 new dental managed care 2018 No No
to dental care. plans were implemented. Between 2013 and 2019 • Integrated MMA and Long-term Care No Yes
2018 there were no fee-for-service dental rate (LTC) program
After more than a decade of litigation, a settle- • No fee-for-service dental services.
increases despite fee-for-service dental services
• Statewide Prepaid Dental Health
ment agreement was approved in June of 2016 being provided. During the same timeframe, the program implemented.
that requires state agencies, the most important data indicates that Florida increased the rates
of which is the Agency for Health Care Administra- paid from Medicaid to Managed Care Organiza- 2020 No Yes
tion (AHCA), make substantial improvements in tions (MCOs) every year, however, we don’t know Sources: KFF (2020); AHCA (2018d)
access to healthcare services so that children en- if these increases were applied to reimbursing
rolled in Medicaid can access medical and dental dental providers. The rates for MCOs continued Similar litigation in Texas serves as an excellent
care throughout Florida. Most notably, as of Oc- to increase in 2019 and 2020, however, again we Case Study: example of how Florida state agencies can utilize
tober 1, 2016, managed care plans are required don’t know we the increases were applied to reim- Medicaid Expansion this lawsuit result as an opportunity to improve
to offer Medicare-equivalent reimbursement bursement rates specifically for dental providers. medical and dental health outcomes for Florida
rates for board-certified pediatricians that meet
in Texas children. When Texas settled their 14-year Med-
objective measures of access and treatment for icaid lawsuit in 2007, they ranked as a bottom 10
children, as increased reimbursement rates have state in providing dental services to their Medic-
been found to result in an increase in the number aid-eligible children. The settlement agreement
of children receiving Medicaid services. ensured that Texas operate their Medicaid pro-
gram in compliance with specific guidelines, which
The Institute’s staff sought to retrieve an update included requirements to increase utilization of
on the settlement and AHCA’s adherence to the dental services through increased access to Med-
evaluation metrics; to date no such update was icaid dental providers. Under the guidance of an
available and our team was unable to uncover advisory committee comprised of dentists, doc-
any of the above information. At the time this re- tors, and representatives from the state Medicaid
agency, the agreement appropriated $707 million
in state general revenue to “increase physician
and dental reimbursement rates, improve out-
1
Managed care plans are a type of health insurance that aim to provide quality health care at an affordable rate. They are dependent on a network of stakeholders, including health care provid-
ers, doctors, and facilities that establish a contract with an insurance provider to offer plans to their members. Members are provided assistance to help in finding the most affordable means of
insurance services based on the healthcare providers who are in their network.
18 2021 RESEARCH REPORT 2021 RESEARCH REPORT 19reach and education to Medicaid-enrolled fam- in Medicaid, providing a roadmap to better health need to investigate the experience of families as nities and obstacles exist for families. The focus
ilies and improve the availability of medical and and social outcomes for children by expanding consumers of these services and the service de- groups (n = 39) and surveys (n = 342) were con-
dental services in rural and border regions of the access (Clark, 2016). With this settlement and oth- livery that was directly contributing to poor oral ducted to inform the following goals and objec-
state” (Texas Medical Association, 2010). Fund- er best practice models, Florida has the opportu- health outcomes in Florida’s children. To under- tives:
ing that was already allocated within House Bill nity to capitalize on lessons learned and employ stand if these preliminary patterns were con-
1, the 2008-2009 appropriations act, was utilized policy for best practices to significantly impact sistent across the state, with support from the The Oral Health Consumer Engage-
to fund physician and dental rate increases. The health outcomes for their most vulnerable chil- DentaQuest Foundation (now the DentaQuest ment research goals:
remaining funds were projected to be paid for by dren. Further, this is an opportunity for the state Partnership for Oral Health Advancement), the In- 1) Understand and offer insight into
applying a funding reduction across-the-board of to work creatively with organizations, dedicated stitute expanded the pilot into a 2-year statewide consumer experiences accessing oral
.59 percent to all ten articles within the budget. To to improving oral health services for children, to study to more broadly capture these experiences health, including perceptions, challeng-
achieve these outcomes, the agreement allocated improve the state of medical and oral health in and understand the collective experience of par- es, barriers and positive experiences,
the following amounts to each act: Florida. ents and children throughout Florida. A brief lit- through the collection of qualitative and
erature review was conducted to provide a foun- quantitative data.
$203 million to fund a 25 percent in- dation for the study (Appendix A). Then using 2) Provide the Florida state Medicaid
crease in physician reimbursement. Oral Health Consumer Engagement Pilot (2014) a mixed-methods approach and qualitative and agency, the Agency for Health Care Ad-
$50 million for targeted rate increases quantitative data collection - administering sur- ministration, the state Surgeon General
for physician subspecialists. In 2014, with the help of partner organizations veys and conducting focus groups – the Institute and Florida Department of Health, and
$258.7 million to fund a 50 percent in- and pilot project funding from the DentaQuest team sought to understand barriers and challeng- other state or local agencies or organi-
crease in dental reimbursement rates. Foundation, FIHI piloted the Oral Health Consum- es when accessing or utilizing care and to capture zations involved in oral health care pol-
$150 million to implement medical and er Engagement project to better understand the positive experiences and referral sources. icies, systems, services and delivery in
dental initiatives such as mobile dental clinics story behind Florida’s oral health statistics for the Florida, with best practices and strate-
in underserved communities, loan forgive- Oral Health Alliance. The Institute team subse- gies for systems change and policy de-
ness programs for physicians and dentists quently designed a survey and conducted a focus velopment to improve access to and uti-
Consumer Engagement
who agree to practice in underserved areas, group with parents in Miami-Dade County to gain lization of oral health care for Florida’s
and/or improved funding for physician train- a snapshot of the Medicaid services consumer ex-
Research: 2015-17 populations.
ing and graduate medical education. perience regarding oral health care for children.
The Consumer Engagement research was con-
$45 million to fund outreach, education, Though, the sample size was small, the results The Oral Health Consumer Engage-
ducted between 2015-17 and was IRB approved
transportation initiatives, and a toll-free ho- were somewhat unexpected. The pilot revealed ment research main objectives:
(Protocol #160021FIHI) with the purpose of con-
tline. that while parents of Medicaid-eligible children in 1) Support the development of a state-
ducting surveys and focus groups with parents to
these two counties were aware of the importance wide consumer engagement infrastruc-
identify barriers to accessing and utilizing dental
This resulted in an increase in young patients ac- of dental health for their children, they were of- ture to improve access to, and utiliza-
care for their children, in an effort to reduce oral
cessing preventive care and a decrease in expen- ten unable to access services due to the limited tion of, preventive oral health care for
health disparities. The IRB letter can be found in
sive procedures and hospitalizations. In 2015, a number of Medicaid providers in their area and Florida’s populations.
Appendix B. The Institute reached out to commu-
study conducted in Texas found that from 2007 lack of flexibility between appointment times 2) Improve practices and policies in the
nity organizations that primarily serve families
to 2011–2012, preventive dental care utilization provided and work schedules. Notably, parents state of Florida by sharing of consumer
enrolled in Medicaid, in rural and urban sites,
among Medicaid-eligible children increased from shared how they felt less valued, received inap- concerns to decision-making institu-
statewide, to collect data from parents accessing
65.9 percent to 80.7 percent in Texas. Additional- propriate and/or inadequate care, and felt that tions, entities, groups and individuals,
community health centers and social service orga-
ly, unmet dental need was found to decline from they couldn’t complain about it since it was a free throughout the state of Florida.
nizations or attending health fairs. A mixed-meth-
4.5 percent in 2007 to 2.4 percent in 2011–201 service. This Consumer Engagement pilot report
ods approach was used to collect qualitative and
(Nasseh & Vujicic, 2015). is available upon request.
quantitative data, with tools, data and analysis re-
viewed by multiple public health specialists. This
Today, Texas is among the top five states provid- The preliminary findings of the pilot, in addition
provided multiple sets of expertise, resulting in a
ing preventive dental services to children enrolled to Florida’s oral health statistics, pointed to a
comprehensive interpretation of what opportu-
20 2021 RESEARCH REPORT 2021 RESEARCH REPORT 21Surveys answering questions relevant to them. Surveys pants skipped the entire survey only filling out the
The complete, full-length English version of the were administered using both a paper format and inclusion form. Likewise, these surveys were ex-
Methodology Consumer Engagement Survey can be found mobile technology (i.e. iPad) depending on pref- cluded from any analysis beyond demographics
The surveys were administered in English and in Appendix C, and the Spanish version can be erence and convenience for participants. In order and the first screening question, bringing the to-
Spanish across the state of Florida. Data collec- found in Appendix D; the online link for both sur- to apply the skip logic to paper surveys, two forms tal number of surveys included in further analysis
tion was facilitated with the help of existing and veys can be found in Appendix E. were used. Depending on how respondents an- to 342.
new community partnerships made up of social swered question #4 (Does your child have a den-
service, philanthropic, and grassroots organiza- Survey data was collected by Institute staff and tist that he/she visits regularly? Yes/No), they con- Using a sample size calculator (Calculator.net)
tions that have direct contact with Medicaid-eli- community partners, as well as trained public tinued with either Form A or Form B (Appendices the Institute staff estimated the minimum sam-
gible populations. The Institute sought to partner health student volunteers and interns who attend- C and D). Institute staff and interns conducting ple size required to show quantified magnitude of
with organizations located in disadvantaged and ed community events, parent education class- the survey were responsible for administering the the result being present in the population. To car-
underserved communities, specifically targeting es, health fairs, and other community programs correct form to participants. The survey did not ry out this calculation, the parameters were de-
the top 10 counties in Florida with the highest where parents in the target population could be collect any information that could be traced back fined as follows: confidence level = 90%; margin
number of Medicaid-eligible children (up to 20 reached. Institute staff scheduled calls with vol- to specific respondents, and responses remained of error = 5%; population proportion = 50%; and
years old) as of June 30, 2016, which included the unteers and community partners to review the confidential and anonymous. The only identifying population size of 2,773,238, the total number of
following counties: 1) Miami-Dade; 2) Broward; 3) survey collection protocol and provide a detailed information collected was from respondents who Medicaid enrolled children in 2016. The results
Hillsborough; 4) Orange; 5) Palm Beach; 6) Duval; overview of our study’s goals and objectives prior chose to participate in our $100 Publix Gift Card indicated that 273 surveys were needed to make
7) Polk; 8) Pinellas; 9) Lee; and 10) Osceola (AHCA, to being in the field. Volunteers and interns were raffle drawing/incentive. At the end of the online statistical inferences about the population based
2015). Existing partners received email commu- additionally required to complete a 15-minute survey, a link brought respondents to a separate on the sample. The Institute collected 342 eligible
nication outlining the Oral Health Consumer En- webinar on proper data collection techniques pri- window that allowed them to enter their contact surveys, indicating statistically significant results.
gagement study and intent along with a request or to assisting in data collection; this webinar link information should they be selected as the prize-
for continued partnership. Outreach to new can be made available upon request. A trained In- winner. This information could not be tied back Surveys completed in paper format were man-
partners involved referrals from the Florida Oral stitute researcher was always present and over- to their survey responses and was only made ually input by Institute staff into SurveyMonkey.
Health Alliance’s Oral Health Consumer Advisory saw volunteers while they conducted the surveys available to the Institute’s staff and interns. For Survey data from 386 surveys was exported via
Council, as well as phone calls and emails to social and collected data. respondents who preferred a hard copy method, SurveyMonkey and analyzed with SPSS statistical
service organizations in counties where the Insti- a separate form was used to collect personal in- analysis software. Using SPSS, the Institute staff
tute lacked existing partnerships. The Institute’s survey was comprised of 40 ques- formation from those interested in signing up for first examined the distribution of responses by
tions that included topics of basic demographic the raffle prize drawing. Again, this information running frequencies of responses from the sur-
information, oral health practices and attitudes, was kept separate from survey responses and veys and respondent demographics. Among the
Study participants were selected based on the barriers to accessing dental care for one’s child, a could not be tied to individual responses; once 386 surveys, the majority of respondents were
following inclusion criteria: participants were par- child’s first dental visit, satisfaction of dental care winners were selected, this information was de- between the age of 25-34 years old (40%) or 35-
ents/caregivers of children up to 17 years old and treatment, and source of oral health information. leted/shredded. 44 years old (30%). Approximately one-third of
full-time residents of the state of Florida. Surveys The survey required an approximate 10 minutes respondents identified as Black or African-Ameri-
began with screening criteria that included a set to complete and was offered in either English or Analysis and Results can (30%), while 25 percent identified as Hispanic
of questions to determine participant eligibility Spanish and digital or print format. The English or Latino, 19 percent identified as White, and 13
and confirmed the following: survey was translated into Spanish and proofread Of the 422 administered surveys, 36 surveys were percent identified as Haitian/Creole. Half of re-
by Spanish-speaking Institute staff. SurveyMon- excluded based on respondents not successfully spondents (53%) were employed full-time at the
1) the participant voluntarily agrees to key, an online survey development cloud-based completing the inclusion form, or not meeting in- time of the survey, while just under half (42%) re-
participate; tool, was chosen to administer and store survey clusion criteria. Three hundred and sixty-two (362) ported an annual combined household income
2) the participant is 18 years of age or old- entries. The survey was designed using skip logic, surveys were completed in English and a total of of less than $20,000 (the next highest percentage
er; and which skips respondents to a future question or 24 surveys were completed in Spanish, bringing of respondents [26%] reported having an annu-
3) the participant is willing to answer page in the survey based on the answer choice the total number of surveys to 386. After further al income of $20,000-$34,999). English was the
questions about their child’s dental care. they select, in order to ensure respondents are review of the survey responses, 44 of the partici- most common primary language spoken among
22 2021 RESEARCH REPORT 2021 RESEARCH REPORT 23You can also read
