[Senate Hearing 108-248] [From the U.S. Government Publishing Office] S. Hrg. 108-248 AGEISM IN HEALTH CARE: ARE OUR NATION'S SENIORS RECEIVING PROPER ORAL HEALTH CARE? ======================================================================= FORUM before the SPECIAL COMMITTEE ON AGING UNITED STATES SENATE ONE HUNDRED EIGHTH CONGRESS FIRST SESSION __________ WASHINGTON, DC __________ SEPTEMBER 22, 2003 __________ Serial No. 108-22 Printed for the use of the Special Committee on Aging U.S. GOVERNMENT PRINTING OFFICE WASHINGTON : 2004 91-118 PDF For Sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800 Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001 SPECIAL COMMITTEE ON AGING LARRY CRAIG, Idaho, Chairman RICHARD SHELBY, Alabama JOHN B. BREAUX, Louisiana, Ranking SUSAN COLLINS, Maine Member MIKE ENZI, Wyoming HARRY REID, Nevada GORDON SMITH, Oregon HERB KOHL, Wisconsin JAMES M. TALENT, Missouri JAMES M. JEFFORDS, Vermont PETER G. FITZGERALD, Illinois RUSSELL D. FEINGOLD, Wisconsin ORRIN G. HATCH, Utah RON WYDEN, Oregon ELIZABETH DOLE, North Carolina BLANCHE L. LINCOLN, Arkansas TED STEVENS, Alaska EVAN BAYH, Indiana RICK SANTORUM, Pennsylvania THOMAS R. CARPER, Delaware DEBBIE STABENOW, Michigan Lupe Wissel, Staff Director Michelle Easton, Ranking Member Staff Director (ii) C O N T E N T S ---------- Page Opening Statement of Senator John Breaux......................... 1 Panel of Witnesses Vice Admiral Richard H. Carmona, Surgeon General, U.S. Department of Health and Human Services, Washington, DC................... 3 Greg J. Folse, Lafayette, LA..................................... 19 Appendix Testimony of Daniel Perry, Executive Director, Alliance for Aging Research....................................................... 61 Statement of Dr. Robert Collins, American Association for Dental Research (AADR)................................................ 66 Statement by Teresa Dolan, American Association of Public Health Dentistry...................................................... 72 Statement submitted by James Harrell, American Dental Association 78 Statement of Dr. Paula K. Friedman, Professor and Associate Dean of Administration, Boston University Goldman School of Dental Medicine, and President American Dental Education Association.. 83 Written statement of Karen Sealander, American Dental Hygienists' Association.................................................... 98 Testimony of Jonathan Musher, MD, on behalf of the American Health Care Association........................................ 124 Statement of Dr. Robert Barsley, Oral Health America............. 127 Statement of Robert J. Klaus, President and CEO, Oral Health America........................................................ 132 Testimony of Dr. Paul Glassman, Associate Dean, Co-Director Center for Oral Health for People with Special Needs, University of the Pacific School of Denstitry, President, Special Care Dentistry......................................... 137 Statement submitted by The Apple Tree Dental Model............... 143 Testimony of Kim Volk, President and CEO, Delta Dental Plans Association.................................................... 150 (iii) FORUM ON AGEISM IN HEALTH CARE: ARE OUR NATION'S SENIORS RECEIVING PROPER ORAL HEALTH CARE? ---------- MONDAY, SEPTEMBER 22, 2003 U.S. Senate, Special Committee on Aging, Washington, DC. The Forum convened, pursuant to notice, at 2:05 p.m., in room SD-628, Dirksen Senate Office Building, Hon. John Breaux, presiding. Present: Senator Breaux. OPENING STATEMENT OF SENATOR JOHN BREAUX Senator Breaux. If everybody would please find a seat, we can begin our afternoon session, and I will do so by welcoming everyone to what is really a forum this afternoon; it is not a formal Aging Committee hearing, but it is an opportunity for all of us who are interested in the question of health care for our Nation's seniors to focus in on one particular aspect of our Nation's health concerns and particularly dealing with our Nation's older Americans, and that is the whole question of proper oral health care, dental care, for our Nation's senior citizens. So I would like to welcome everyone to this session this afternoon, and I want to thank the Chairman of the Aging Committee, Senator Craig, for his cooperation and support and assistance for allowing us to meet and have this discussion. This afternoon we will focus on the question of whether older Americans are receiving proper oral health care. I think the purpose is really threefold--first, to define the oral health issues that are facing our Nation's seniors today, and second, to try to develop and discuss some potential solutions to the problems that exist; and third, to alert Americans about the opportunities they have to help improve health care, particularly oral health care, for America's elderly. Although there have clearly been dramatic improvements in oral health care during the last 50 years, profound disparities continue to exist for those without the knowledge, the resources, or the capability to achieve good-quality oral health care. This certainly includes our poor and vulnerable elderly and disabled adults, and poor oral health care causes suffering to millions of Americans and obviously particularly to our most vulnerable population. Twenty-three percent of the 65- to 74-year-olds have severe periodontal or gum disease. The percentage of risk increases, of course, as people age. People at the lowest socioeconomic levels have even more severe periodontal disease. Oral and pharyngeal cancers are diagnosed in about 30,000 Americans annually, and 8,000 die from these diseases every year, which are primarily diagnosed in the elderly, and their prognosis is very poor. Fewer than 2 out of every 10 older Americans are covered by private dental insurance. Uninsured Americans with severe oral disease often end up in hospital emergency rooms, where the problem is addressed with painkillers and/or tooth extractions, both of which are obviously only a temporary fix, wasting millions of taxpayer dollars every year. Recent research has further highlighted the results of poor oral health care. Studies have shown a connection between chronic oral infections and heart and lung disease and stroke and diabetes and premature birth. Infections resulting from oral infections place individuals at serious risk of death. Infectious diseases of the mouth left untreated can cause undue pain and suffering and poor quality of life, and even death. Clearly, all Americans need to be aware of the need for good oral health. However, our emphasis today is on grappling with how best to ensure that our older Americans receive proper oral health care. It is my hope that this forum will accentuate the importance of oral health. Thanks to the generous support of Oral Health America, we are releasing a report today entitled ``A State of Decay: Oral Health of Older Americans.'' As you can see from the charts behind me, Oral Health America surveyed all 50 States and the District of Columbia on the extent of the oral health care services for Medicaid adults. As a part of this study, a report card was developed that reflects predominantly failing grades in all jurisdictions, giving the United States a score of ``D'' as our national average. It is very alarming, considering the severe health consequences and resulting cost of poor oral health care. I thank each and every one of you for being with us and for your participation and look forward to hearing from you as we discuss this issue. I would first like to welcome the Surgeon General, who is a surgeon but not a general, but he is an admiral, and we are very pleased to welcome Vice Admiral Richard Carmona, who is our Surgeon General. Vice Admiral Carmona was sworn in as the 17th Surgeon General of the United States Public Health Service in August 2002. He is a decorated veteran and graduate of the University of California Medical School. Dr. Carmona has published extensively and received numerous awards, decorations, and local and national recognition for his achievements. We thank him for participating and for his support. I would also like to introduce Dr. Greg Folse, who is a practicing dentist from Lafayette, in my State of Louisiana. He was instrumental in drawing my attention in the beginning to the critical issues surrounding oral health of the elderly. He has a mobile geriatric dental practice and also works with the American Dental Association and Special Care Dentistry to improve oral access for special needs patients. He is really very passionate about caring for the oral health of the elderly and carries out that mission every day of his life. I have seen the slide presentation that Greg will make to us this afternoon. It is most impressive in highlighting the serious nature of the problem that we face as a Nation. I would also like to say thanks to all of the organizations represented here this afternoon. I am pleased to introduce these organizations and the representatives who are here today. Your biographies are all included in our official record, and I will simply recognize you for the sake of brevity: From the Alliance for Aging Research, Dan Perry. Dan, thank you for being with us; from the American Association for Dental Research, Dr. Robert Collins; from the American Association of Public Health Dentistry, Dr. Teresa Dolan; from the American Dental Association, Dr. James Harrell; from the American Dental Education Association, Dr. Paula Friedman; from the American Dental Hygienists' Association, Karen Sealander; from the American Health Care Association, Dr. Jonathan Musher; the CMMS-HHS chief dental officer, Dr. Conan Davis; from Louisiana State Dental Medicaid Services, Dr. Robert Barsley; from Oral Health America--thank you for the good work--Dr. Robert Klaus; from Special Care Dentistry, Dr. Paul Glassman. Thank you all. I would like to also introduce Janet Heinrich, who is with GAO, the Government Accounting Office's Director of Health Care and Public Health Issues. She has put together and led many of the health studies that we have utilized, both in the Finance Committee and in our committee on elderly issues, for the U.S. Senate and for the Congress, and we appreciate once again her doing the work. We are going to ask her to moderate if I have to leave some of the discussion, Janet, if that would be all right with you. Ms. Heinrich. Yes. Senator Breaux. Our format will be to first hear from our Surgeon General, Dr. Carmona. If you would go ahead and lead us off, we would appreciate hearing from you, and then we will go to Dr. Folse and his slide presentation. Mr. Surgeon General, we are delighted to have you with us. STATEMENT OF VICE ADMIRAL RICHARD H. CARMONA, SURGEON GENERAL, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC Dr. Carmona. Thank you, Senator. It is nice to be here. Thank you for taking the leadership in this very important area. My name is Richard Carmona. I am the United States Surgeon General, and as an American, I want to take this opportunity to thank all of you for the service that you have provided to the Nation in keeping this very important issue on the forefront. I have had the honor of working with many of you during my first year as Surgeon General and look forward to strengthening our partnerships to improve the health and well-being of all Americans. Senator, you have been a leader in addressing the health needs of America in general and its seniors, and I thank you so much for continuing to take the lead in those issues. It was a pleasure participating with Senator Craig, another leader, just recently in a Montana Health Summit, and Senator Burns, who also understand the value of public health and keeping our citizens healthy. Today I welcome the opportunity to talk with this committee about the oral health of America's seniors. While oral health is tremendously important, I am sure I do not have to tell you that it does not receive much attention. For that reason, I appreciate the focus of this forum, especially in the context of a holistic approach to disease prevention. Poor oral health adversely affects all aspects of life. Kids cannot learn in school if they are in pain. Adults miss work due to dental pain and tooth and gum decay. Twenty-two percent of adults report having some oral pain in the past 6 months. Oral and pharyngeal cancers, primarily found in the elderly, are diagnosed in about 30,000 Americans annually. Tragically, 8,000 Americans die from these diseases each year. ``Oral Health in America,'' a report of the Surgeon General, recognizes that such oral health is essential to general well-being and that the oral health of America's seniors is today an acute problem. The facts are staggering. About 30 percent of individuals 65 years and older have lost all their teeth. The rate of oral and pharyngeal cancers is higher among seniors than for any other age group. Americans 65 years and older are seven times more likely to be diagnosed with oral cancer than younger individuals. The vast majority of payment for dental services is out-of- pocket for older people, with only rare exceptions. Medicare does not cover the cost of oral health services. This results in compromised access for our seniors. While 61 percent of the general population reports having a dental visit in the past year, only 45 percent of seniors 75 years and older report seeing a dental professional in that same time period. A number of HHS programs focus on oral health needs of seniors. HRSA's oral health program is increasing access to oral health care through its 843 health center grantees. Seventy-two percent of these centers offer preventive dental care. Also, NIH's National Institute of Dental Health of Dental and Craniofacial Research reports many clinical trials related to the oral health of seniors. In addition, CDC's division of oral health supports oral health projects in predominantly poor, ethnically diverse communities. These projects include: mobilizing community health workers to improve oral health practices in rural Alabama; setting up an oral health training program for nurses who care for homebound seniors in Harlem, which is my old neighborhood; and in Washington State, training seniors to be oral health educators for children, which improves the health of the kids and the seniors. As you know, in April of this year, I released a National Call to Action to Promote Oral Health. The Call to Action is a guide for our efforts to improve oral health. It outlines five action areas. First, we need to change the perceptions of oral health. We can no longer afford to have Americans believe that oral health is separate from general health and well-being. Improving health literacy is key to improving America's oral health. Second is to replicate effective programs and proven efforts. Best practices in oral health must be recognized and replicated in every State. Third is to build the science base. Biomedical and behavioral research is transforming our knowledge of prevention, diagnosis, and treatment of oral diseases. This knowledge must be turned into action. Fourth is to increase oral health workforce diversity, capacity, and flexibility. Women and minorities are under represented in the dental profession. We must encourage diversity and use culturally competent messages to eliminate disparities in oral health. Fifth and finally is to increase collaborations. Disease prevention and health promotion campaigns that affect oral health, such as proper brushing and flossing and regular checkups, as well as tobacco control and nutrition counseling, can lead to improved oral health for all Americans. The prevention message that President Bush, Secretary Thompson and I have been emphasizing is applicable to ensuring good oral health. For example, there are simple steps that any person can take to prevent dental diseases. They are: proper brushing and flossing; use of fluoride rinse or toothpaste; regular visits to the dentist; healthy eating; limiting alcohol use and avoiding tobacco. In particular, tobacco use, whether cigarettes, cigar, or smokeless tobacco, frequently results in oral cancers. Most people, even many health professionals, do not know that smoking causes over 50 percent of the periodontal disease in the United States. We need to get this information to the public and to health professionals. Again, it is an issue of health literacy. It is a battle in many areas of public health that I find, increasing health literacy so that people understand the good science that we have already available and we are not using it fully. In closing, I will add that today must be a day of change. Today must be a day when our work is a catalyst for better oral health. I thank you for many efforts on behalf of seniors, and I promise to work with you to improve the health and well-being of all Americans. With that, I will end my oral remarks. I would ask to be able to submit my entire written statement into the record, and I would also be happy to answer any questions, Senator. Thank you very much. Senator Breaux. Thank you, Dr. Carmona. I understand that you need to catch a plane, so we are not going to keep you too long. I am going to let you be excused whenever you feel that you have to. Dr. Carmona. Thank you, sir. Senator Breaux. But I want to thank you for your participation. I think that a lot of people do not understand the serious nature of the problem, and I think that you as the Surgeon General obviously have the capacity to highlight the serious nature of oral health care for seniors at a time when many Americans seem to be more concerned about the color of their teeth; they want to make them whiter, and there are more and more products for whiter teeth and how you can get them to be brighter and brighter. There are many older Americans who are suffering very severe health problems, not because of lack of white teeth but because of severe infections and other problems that they have. So in your capacity as Surgeon General, I think it is important that you make the statement that you made today and continue to try to highlight this as a particular problem and a particular concern. So we thank you for being with us and hope you can continue helping to educate the American public about this very serious problem. You may be excused whenever you have to go because you have told me that you need to catch a plane for a trip. Dr. Carmona. Thank you, Senator. I would just add that, as I said when we released the report, you have my full commitment as does the American public in keeping this area of oral health on the forefront. Thank you, sir. Senator Breaux. Thank you, Admiral. [The prepared statement of Dr. Carmona follows:] [GRAPHIC] [TIFF OMITTED] T1118.001 [GRAPHIC] [TIFF OMITTED] T1118.002 [GRAPHIC] [TIFF OMITTED] T1118.003 [GRAPHIC] [TIFF OMITTED] T1118.004 [GRAPHIC] [TIFF OMITTED] T1118.005 [GRAPHIC] [TIFF OMITTED] T1118.006 [GRAPHIC] [TIFF OMITTED] T1118.007 [GRAPHIC] [TIFF OMITTED] T1118.008 [GRAPHIC] [TIFF OMITTED] T1118.009 [GRAPHIC] [TIFF OMITTED] T1118.010 [GRAPHIC] [TIFF OMITTED] T1118.011 [GRAPHIC] [TIFF OMITTED] T1118.012 Senator Breaux. Now let us ask Greg to make his slide presentation, and then we will be able to begin the dialog that I hope we can get on trying to find out what we need to be doing. Dr. Folse. STATEMENT OF GREG J. FOLSE, LAFAYETTE, LA Dr. Folse. I want to thank you very much, Senator Breaux, for bringing us all together today. You talked about the whitening--I think the color that my patients would really like to have their teeth is ``some.'' Unfortunately, that is where we are. That is one of the things that Louisiana happens to do well, actually. We have a good denture program for our elderly, but we do not pay for a lot of other things. I also want to thank Dr. Carmona in his absence for his call to action. I think it is already affecting lives. But we have a long way to go. Ageism and oral health--are our Nation's seniors receiving proper oral health care? The answer is resoundingly no--they are not receiving it right now when you look across the board. The Surgeon General's report in 2000 called it ``a silent epidemic'' for our elderly. I think that when you really look at it, and you see the patients that I see--and let me back up a little bit. I have a mobile geriatric practice, and I go to nursing homes every day; I am in there day in and day out. When you see what I see, it is not silent--it screams. It screams for us to take action on the issue. This is Miss Sylvia. I am going to introduce you today to a few patients of mine, and if you cannot see, please get up and move around; that is fine with me. Ms. Sylvia was the mother of a nursing home administrator. She had just arrived at the facility. She was poor. She had been in the community. You will notice her hair is pretty; she has it all combed. She was really trying to take care of herself. She has lipstick and rouge, and everything was Cadillac-ing for her--except when you looked in her mouth. She did not have access to oral health services. She did not go and have her teeth cleaned. She had gum disease. She had broken teeth. She had abscesses in the back of her mouth. She had infection. We cannot stand for this. Her daughter cared dearly for her and did not really realize that this was going on. This is Mr. Joe, an old man in a facility--I work in facilities all day, and I love nursing facilities. It is not that he was there, but there is a great burden of disease when these patients get into nursing facilities, and that burden is difficult for us to deal with. He had a tooth, which you can see right her, that they asked me to take a look at. When I did, they told me his story. He was a grumpy guy who would sit in his wheelchair and literally run the wheelchair into your ankles. He was ornery and hated everybody, and nobody liked him. Well, when I looked in his mouth, under his lip was this huge squamous cell carcinoma. This guy thought he was dying; his face was rotting off. This cannot be. Had he had one dental evaluation, one cleaning, while he was getting older, someone would have picked this up. We did radiation therapy, this became a little scar, and the guy did very well. He started going to bingo and became a good part of the facility. Who are these patients? When I look at the country, I had this term introduced to me not too long ago--the ``aged, blind, and disabled.'' If we can think about our seniors and our vulnerable adult population and use this term, we will be ahead of the game, because this term is defined in Social Security law, so it is a great place to hang our access hat. This gentleman, Mr. Charles, is a good representative of ``aged, blind, and disabled.'' He is all three of them. He was in a facility, and I told him 2 months ago, ``I am going to Washington. I am going to try to get some help for your teeth.'' He was all happy, and he gave me this kind of convoluted smile that you can see here. He was happy about it. He allowed me to take photographs of his mouth, and today he sits in this facility with no access to oral health care with these teeth. This is how he eats every day. He has broken teeth, he has gum disease, he has abscesses. These are teeth that are broken off at the gum line, for those of you who do not know. When I told him that I was going to Washington just to talk, he thought I was going to take his teeth out that day, and he got angry; and when he did, this was the face he made, and I just quickly took a shot of it. I am with you, Mr. Charles; I feel the same way. Let us do something. How many of them are there? In my written testimony, I have some actual numbers of disabled adults, but we all know that the number of seniors in our country is going through the roof. Just like Miss Marsha--these slides I took a month ago--6 months ago, she had an abscess for this little tooth, right here. This tooth needed extraction 6 months ago. There is no access in our State, along with other States--I will tell you how many in a little while. I put her on antibiotics. Someone else put her on antibiotics a month later, and someone else again a month after that. A $100 extraction would have taken care of this. The fourth time she got infected, she got an MRSA infection, which is a staph infection that is resistant to antibiotics. She had to go in the hospital--and that is where these pictures were taken-- so that they could do a little surgical procedure, a drainage here. During the procedure, she was septic, and her heart stopped beating, so she went into the ICU for 4 days. One hundred dollars for an extraction, $30,000 for a surgery and ICU stay. It does not make a lot of sense, besides the suffering that this lady had to go through. As a practitioner, it kills me, because they sit and they rot under my care, and I hate it. Guys like me all across the country see the oral health of our seniors is neglected. The report from the Surgeon General said there are many disparities, and there are. The elderly take the brunt of it. If you have money, you can get care--until you get medically or functionally disabled, or until you get institutionalized or you spend all of your money. Then you start losing that access that we all have as functional adults. Within the ``age, blind, and disabled''--and I realize this is not quite as on-point--but we have mentally retarded adults in our country who sit in facilities or who sit at home with no access to oral health care. This is a sin that our mentally retarded do not have access. This poor gentleman sits--he is losing his teeth, he has gum disease, he has abscesses--and there is nothing I can do about it. There are hundreds and thousands of them across the country like this. We have to do something on a national level. I wish the Surgeon General was here for this. We need a statement from him saying that oral health services are medically necessary for this vulnerable population. I think that is going to be a key to the advocacy or the push to get services. It goes on and on, people. I saw this guy, and 2 years before I took this photograph, these four teeth were in perfect shape; he had a $900 partial hooked to it that he was eating with. Two years later, after a stroke, he has gum disease, he bleeds every time he eats--and no access to care. This is the old tooth in the lung, another $100 extraction that turned into a $40,000 or $50,000 surgical procedure and hospital stay with all these complications. A loose tooth--she rolled over, hit her mouth on the bed rail, and it went into her lung. This is a birth mark. Miss Mary had this birth mark all her life. But what I want you to look at are her eyes. Do you see that? Two weeks before I took these photographs, Miss Mary was walking and talking. She developed a dental abscess. Had she had any access over the last few years of her life, they would have caught something. Miss Mary, you can see, is swollen here; actually, she has some purulent drainage down on her bib. This was in the front of her mouth. I would think that this tumor would have been caught by somebody had we had access to oral health for an aged, blind, and disabled adult. She could have gone somewhere. Miss Mary died from the infection that got into this tumor. They could not take care of it. Seven days after I took these photographs, she passed away and really has solidly put the need for what we are doing here today in me. My wife will kill me, but I offer my services to all of you as we go through this process of getting access for these patients to help in any way I can. What benefits are available? The Surgeon General talked about it. There is virtually nothing until you get down to Medicaid--virtually no Medicare, private insurance, applied income laws. Medicaid has optional programs for every State. States can individually choose whether they want dental services or not. This is what our country looks like--blue is a B; New York gets a B--as far as Medicaid services go. The green States are C's. The yellow States are D's, and the red States are F's. I got to pick the colors, too--it is pus yellow and blood red-- and I am not going to apologize for it. It is a sin. We have 45 States with a D or an F, and when you look at the service reimbursements--and all of this is included in the Oral Health Report Card from Oral Health America, which I thank you guys for doing; it was great to be a part of that--when you look at the service reimbursements for the providers out there, all States except one get a D or an F. So when I couple the D-minus grade for Medicaid with the vulnerability of the ``aged, blind, and disabled,'' I give our country an F on how we are doing. Do we get it yet? There is nothing out there for these adults. The system of optional Medicaid oral health benefits is not working. We have in essence designated treatment of pain, pus, infection, and swelling as ``optional,'' and it does not make sense, and I know you all agree with me. So nationally, unfortunately, we have no infrastructure for oral health for ``aged, blind, and disabled.'' We do, however, have an infrastructure for children under EPSDT, and this is where I really think the solution can come. I believe that if we could take the ``aged, blind, and disabled'' who are already approved for Medicaid and put them into coverage under EPSDT or in a system like that, I really believe that that would work. National solutions--again, we need a bill, and I know that you will be open to helping us with that with the ABD patients. Within my testimony, I have included kind of the guts of that idea of the ``aged, blind, and disabled oral health access proposal''; it is in my written testimony. I would love to see a declaration that oral health services are definitely medically necessary. I would like to see the formation of a National Oral Health Coalition for Special Needs Adults, and a dental director in every nursing home. It can be done well. This is Miss Daisy. I made these dentures for her when she was 103 years old. Miss Daisy lost them 4 years later, and I remade them. Miss Daisy wore those dentures until she was 112 before she passed away. She had good oral health, and it meant a lot to her. We can do that on a national level. I thank you all very much for being here, and I thank you for participating in this event. Thank you, Senator Breaux. [Applause.] [The prepared statement of Dr. Folse follows:] [GRAPHIC] [TIFF OMITTED] T1118.013 [GRAPHIC] [TIFF OMITTED] T1118.014 [GRAPHIC] [TIFF OMITTED] T1118.015 [GRAPHIC] [TIFF OMITTED] T1118.016 [GRAPHIC] [TIFF OMITTED] T1118.017 [GRAPHIC] [TIFF OMITTED] T1118.018 [GRAPHIC] [TIFF OMITTED] T1118.019 [GRAPHIC] [TIFF OMITTED] T1118.020 [GRAPHIC] [TIFF OMITTED] T1118.021 [GRAPHIC] [TIFF OMITTED] T1118.022 [GRAPHIC] [TIFF OMITTED] T1118.023 Senator Breaux. Thank you very much, Greg. I met with Greg previous, and I had seen his presentation back in Louisiana, and it was what really got me interested in trying to figure out where we are as a Nation with regard to oral health care for seniors. Let me just start--and I want you all to enter into discussion, not me--I would rather just sit and listen--but Greg, you made a statement that Louisiana has a good program. Dr. Folse. For denture care only. Senator Breaux. Oh, for denture care. Explain the difference between oral health care and just denture care that we have in Louisiana. Dr. Folse. Oral health care would include extractions, would include all the preventive services, exams, x-rays, getting teeth cleaned, gum disease treatment, fillings. That is an oral health care program. What we do is only the prosthetic side, which is a piece and an important piece of oral health, but we make dentures. We do not take out bad teeth to give you dentures, but we do provide dentures for patients whose teeth are already gone. Senator Breaux. That is really interesting; we are after the fact. Dr. Folse. The program was started years ago when most of our elders--in our State, probably 65, 70 percent of our elders had no teeth. Now I am seeing only about 40 percent; so I am seeing 60 percent with teeth now. So back then when they started that program, a majority of the population was affected by it in a positive way. So it made sense back then. Senator Breaux. So the State Medicaid program covers the dentures? Dr. Folse. Yes, sir, they do. Senator Breaux. You are really pointing out something. Older citizens, like my grandparents' generation, were just expected to lose their teeth and never to have all of their teeth. Dr. Folse. Exactly, yes, sir. Senator Breaux. OK. The information is obviously very graphic. I think we have a problem, and the question is how extensive is the problem. Can anybody talk about that a little bit? I have seen Lafayette, and I have seen Louisiana, but what about the study that we did with oral health? Robert, do you want to comment on that? How did you all do the survey? Dr. Klaus. We surveyed Medicaid dental contacts across the United States. I would suggest that the study results that we see here today are really the tip of the iceberg, that the problem is probably far more serious than even we would come out and say. Senator Breaux. What kinds of programs do we have for oral health care among the States? I guess the States' obligation would be under the Medicaid program for the low-income. Dr. Klaus. Medicaid--but under the Medicaid program, the first thing to be cut when times get tough in State legislatures as they are now, with States facing huge deficits, is the dental benefits of Medicaid. Recently, Michigan cut all Medicaid benefits except for those that relate to emergencies. We think that this pattern is going to continue. I just heard this morning from people in Georgia that next year, they think they are going to cut back on their dental benefits for Medicaid. Senator Breaux. Is the best that any State has under Medicaid an optional program that covers dental? Dr. Klaus. Yes. They are all optional. Senator Breaux. They are all optional, and many of them do not even have them as an option. Dr. Klaus. No, many of they do not have them as an option. Senator Breaux. Greg. Dr. Folse. Correct. The children's program is not optional, but all programs for adults are. You get a range of different types of programs. Minnesota right now is doing very well with their program. There are little problems within individual programs, and as a whole, you have Medicaid issues nationally. But it is optional versus non-optional. So from Minnesota, which is doing well, treating a lot of nursing home patients and a lot of elderly across the State, it goes down to States with absolutely nothing, not even a denture program; so you have us all in the range. The effectiveness of those programs, though, comes in when you really grade it, and that is what the report card did. We cut out five different procedures and looked at the reimbursement rates and said what dentist is going to do this for these types of fees, and that is where we got all the D's and F's. It was just way below what is out there. Senator Breaux. We sent all of you some questions, and I want to try to keep it focused to a certain extent. The first question is: What is the greatest problem that seniors face where oral health is concerned? If you are poor, the greatest problem is you do not have it. Anybody can start to comment on this. My father fortunately has access to his employer's retirement health program that covers dental care. He probably also has enough money that if he did not have that insurance, he could afford to go to a dentist and pay the bill. But that is probably not the situation for most Americans. Let us talk about that. Paula. Dr. Friedman. Senator, thank you for this opportunity to comment. I think that this is a tremendously important issue, and I would suggest that we consider, in additional to the financial means to access care, the dearth of qualified providers. One of the reasons that there is a problem certainly is financial, but another level of problem is that there are so very few qualified people trained in geriatric dentistry. A few of them happen to be seated around this table. But I would ask you to think about how many dentists are trained annually to provide the special training to provide care to senior citizens. I am not going to put you on the spot, but I am sure you would not imagine. Under HRSA--and we are grateful for the support that HRSA provides toward training geriatric physicians and dentists--less than 10 dentists a year for the entire country are trained in providing special services to this frail elderly population with medically compromised, complex medical conditions. So I certainly recognize the financial aspect, no question about that, but I am sure that my friend and colleague Dr. Folse would agree with me that access is also a function of having qualified providers. Dr. Folse. Without a doubt. It is kind of what comes first, the chicken or the egg, because I have had 3 years of extra training so that I could take literally a 50 percent pay cut over my colleagues. So what is going to come first? I do not think we could get the--you almost have to have the financial infrastructure at the same time. I do not care which one gets there faster. We have got to do both of them, and you are exactly right. Dr. Friedman. You certainly have to address both. I happen to be one of the dental directors of one of the HRSA-funded geriatric dentistry and medicine training programs, so I can tell you that there are only five to seven dentists per year in the entire country. Senator Breaux. Well, we only have five medical schools, and we just recently picked up two more, but out of all the medical schools in the country, 113 or so, there are only five that offer graduate programs in geriatrics. It is the fastest growing segment of our population in America, and yet only five medical schools offer advanced degrees in geriatric specialties. So when you break it down to subspecialties of dentistry, you can understand why we only have 10 graduates a year. Yes, Mr. Harrell. Dr. Harrell. I am a consultant to a nursing home, which I do mostly on a free basis--I take a 100 percent cut--and we have a Medicaid program that covers adults, although the reimbursement rates are extremely low, sometimes as low as 14 to 16 percent of cost. Senator Breaux. Who has the program? Dr. Harrell. North Carolina. Senator Breaux. Oh, the State does--under the Medicaid program? Dr. Harrell. Although we fear we are going to lose it. I think the only reason we came out so well this year was the one-time Medicaid reimbursement to the States which saved us from probably a lot of lobbying and a lot of heartache. But this is going to come back again next year. But it is a financial issue. As a family dentist, I see geriatric patients in my office on a daily basis. A lot of them have insurance or can afford it otherwise, or they would have Medicaid. But going into a nursing home facility--I serve three--there are no facilities, no equipment. The nurses and staff know very little about oral health, and most of the time you are doing extraction in the middle of the night with a weak flashlight battery, and they always feed them right before you get there. I do not understand that. So I know we need geriatric dentists--I am not underplaying that--but we need to stimulate family dentists. Senator Breaux. I would think--and I am obviously not a medical doctor--but it would seem to me that the fact that we do not have a lot of geriatric dental specialists, it seems to me that any doctor of general dentistry can look at these seniors and the problems they have are no different than those of a young child who has not been to a dentist in 15 years of his life. I mean, a practicing dentist would be able to look at an elderly person just like he does a person who has never seen a dentist who is 20 years old as the same types of problems develop. There are a lot of other problems, particularly mental illness and others, that seem to be a lot different among the elderly and more difficult to recognize that it is a problem of aging. Dr. Harrell. There are special needs patients that you cannot treat without some type of facilities, and in a lot of places, we do not have those. Senator Breaux. I would bet you there is not a nursing home anywhere in the country that has a resident dentist. Dr. Folse. I am actually a dental director in 14 nursing homes now, and I am there usually a time or two a week, and we do all of our services. I do do some extractions and cleanings and those kinds of things at the facility---- Senator Breaux. But how many other dentists do that? Dr. Folse. Not many. To build the infrastructure that we are going to need to get people doing those kinds of services, one of the things is to take away the yearly budgetary threat that we get from Medicaid on a State-by-State basis. That has a significant impact when you have a system built to treat vulnerable adults, but it is always on target. I have trouble getting other dentists to do that when the States pull the rug out from under us every year. Senator Breaux. But what kind of compensation does a dentist who does what you do get? Is he reimbursed anywhere? Dr. Folse. I am reimbursed for the denture care, and a lot of the other stuff is donated. Senator Breaux. We know these other problems are not denture problems; they are just gum disease problems. You are not going to be reimbursed zip for that. Dr. Folse. But I am not treating it, either. It is sad. I have 2,500 patients, and 1,600 patients have cavities and gum disease under my watch, and they do not get treated. I put the fires out as much as I can. I treat the ones that the families will let me treat. But as a whole, having an infrastructure where guys in an office could get paid to see these patients and I could refer them to you would be great. Senator Breaux. Are there any other comments from anybody? Dr. Barsley. Dr. Barsley. Senator Breaux, I appreciate the opportunity to be here today. I have worked with Dr. Folse over the years in Louisiana, and one of our problems has been I have pulled the rug out from under Greg more than once when our State ran out of funds; I have reduced the amount of money that we can pay to him. Fortunately this year, we were able to increase that amount of money, and one thing we thought about doing was increasing the services that were offered. Our problem was that the pent-up demand is so vast that once we increase the range of services we can offer, we have no way to judge how much pent-up demand there would be; if we had to extract just one tooth in every person in Louisiana who is Medicaid-eligible, that is one million teeth. Senator Breaux. How much do we pay for dentures? Dr. Barsley. We pay roughly $1,000 in Louisiana. Senator Breaux. I mean what is the total cost. Dr. Barsley. In Louisiana, our budget for adult services is about $4 million. Senator Breaux. Four million dollars for dentures. Dr. Barsley. For dentures only and the exams that go with them, yes, Senator. Senator Breaux. Suppose we just did not do dentures, and we used the $4 million for oral health? Dr. Barsley. That is what I am looking at. Dr. Folse. Yes. Senator Breaux. Is there any prohibition--I mean, could a State do that if it wanted to? Dr. Barsley. Senator, we could, but I am very much afraid-- in fact, we are discussing this very weekend adding dental care for adult pregnant women to help decrease low birth-weight children. We are estimating that adding extractions and cleaning their teeth will probably cost about $3 to $4 million for the 30,000 women who would be covered in the next year. So if we were to cover all the Medicaid-eligible people in Louisiana and cover a range of services limited just to that-- -- Senator Breaux. Does anybody know if any other States just cover dentures? Dr. Folse. That is optional. I mean, you can cover whatever set of benefits you want. Senator Breaux. Yes, I know, but I think it is unusual that we cover dentures but not oral health. Dr. Folse. Yes. Dr. Dolan. Senator, the State of Florida had an adult denture program until about 2 years ago, and when they had Medicaid cuts, they eliminated that program. That is why my State is a ``red'' State on Dr. Folse's chart, because actually, we have one of the highest proportions of older adults in the United States, and yet we do not have the ability to serve the needs of those individuals. Senator Breaux. So Florida is not able to do dentures or anything else in oral health? Dr. Dolan. No. In fact, I was the dental director for four nursing facilities in Florida as part of my teaching responsibilities at the University of Florida and was faced with the same frustrations that you face every day in that you try to do the right thing for these individuals, and yet there was not the public or private financing to meet the needs of the residents of these facilities. Dr. Folse. Senator, I beg your forgiveness for the interruption. You are talking about cost. In special care dentistry, we looked at the problem of including oral health for adults in Medicaid, and when you cover the whole population, it costs a lot of money. You are really in a jam. You are not able under Medicaid to carve out like ``aged, blind, and disabled.'' If we could carve out ``aged, blind, and disabled,'' which is the most vulnerable population, and cover them under Medicaid, that is a doable thing. We put together as part of my written testimony the proposal--we looked at what California spent on ``aged, blind, and disabled''--and they have full dental benefits there--and we extrapolated that out to the country, and it looked like about $1.2 billion a year if you put those patients under the dental programs that are currently there. That is pretty much a max, because some of those patients are already being treated, so the ones like California would be included in that $1.2 billion, so we are already spending that. It would probably add from our estimation about $700 million a year to the country to treat ``aged, blind, and disabled'' under Medicaid. It just makes sense. Senator Breaux. Would you have to drop others--aren't children included? Dr. Folse. Children are covered now under Medicaid; correct. Senator Breaux. You are not talking about dropping them. Dr. Folse. No. I am talking about just adding ABD adults into the EPSDT program that is already existing in all the States. Senator Breaux. Does anybody have any thoughts about that? Yes, Paul? Dr. Glassman. Paul Glassman, from Special Care Dentistry. Thank you for the opportunity to be here. Greg is referring to some data that we did collect in California, where the people who were in that category, adults who are ``aged, blind, and disabled,'' account for 33 percent of the Medicaid population in California and currently use about 20 percent of the Medicaid dollars. So that is where the numbers came from to extrapolate what it would cost nationally. California actually received a C-plus on the chart, which was one of the three highest States because of that program-- although that program has been threatened and almost went away this year. Again, the one-time block grants to the States saved it from being removed this year. I also wanted to comment that--you asked earlier about data--in the recent Surgeon General's Report on Oral Health in America, it actually says in the report that one of the problems when you are talking about special populations is that there really is not any good data, and it actually talks about that in the report. I am president this year of Special Care Dentistry, and we have 1,000 members, which is a small group of very dedicated people who spend their lives treating people who are aged, blind, and disabled, and each one of those people has a thousand stories. So there is no question in our minds that this is a huge problem. The numbers are staggering, but as Greg says, it tends to be a silent epidemic because the people who are suffering really do not have a voice to let their suffering be known. Senator Breaux. Tell me again what is your situation in California. The aged, blind, and disabled constitute about 33 percent? Dr. Glassman. We have an adult Medicaid program for dentistry, so adult Medicaid recipients are covered by dental benefits. Of those who are covered, about 25 percent fall into the category of ``aged, blind, and disabled,'' and they use about 20 percent of the Medicaid expenditures. Senator Breaux. What does the program in California cover? Dr. Glassman. I cover all the kinds of things that Dr. Folse was talking about--basic examinations, cleanings, fillings, extractions, treatment of infections, screening for oral cancer. It does cover dentures. Some people say that it does not cover enough, but I actually think it is a very good program for basic services. Senator Breaux. But how did they only get a C if they cover all that? Dr. Klaus. Because they missed in other major--I do not have the report right in front of me, Senator--but they missed in other major categories. Paul, you probably know those better than I do. Dr. Glassman. I think it is actually a good program compared to many States in the country. It certainly has its problems, and I think that is where the C came from. Senator Breaux. So you miss seniors who are not aged or disabled or blind; they are not covered? Dr. Glassman. Yes, that is right. Low-income seniors are covered. Senator Breaux. All low-income seniors eligible for Medicaid have dentistry as an option. Dr. Glassman. Right, yes. Most people who are eligible for Medicaid gets dental benefits, right. Dr. Folse. Their low grade came from real low reimbursement rates. Senator Breaux. Other than that, they have a good program. It is just a question of the reimbursement rates--because the services are provided. Dr. Folse. Yes. A lot of the States have full coverage is what they say, but when you look at the effectiveness of that coverage, because it is below the tenth percentile of what dentists charge, it is real hard to get the infrastructure. Senator Breaux. That is true of everything--in the CHIP program in my State of Louisiana, we have insurance for children under the Medicaid program, but the reimbursement rate is so low that many doctors refuse to take children as patients because of the reimbursement rate. It is all a question of money, isn't it? Dr. Folse. Yes. Senator Breaux. Is there other discussion on this? Yes? Dr. Harrell. I wanted to bring up the reimbursement to make sure you are clear. States have programs; it does not necessarily mean they fund those at a reimbursement level adequate enough for people to have access. In North Carolina, by a funny twist, the State was just successfully sued by a children's advocacy group because they did not raise the fees, the reimbursement, enough to allow the required access. The funny thing is--not funny--but the nice irony is that they did it by codes, and a lot of those codes are also adult codes. So that is going to help our geriatric Medicaid population also. But just because you have children's Medicaid or a Medicaid program does not necessarily mean you are providing access. Senator Breaux. Let me understand. How many States have dentistry covered under the Medicaid program, regardless of the reimbursement rates? Dr. Folse. Virtually all of them. Senator Breaux. So all of them do--Louisiana, too? I thought we just covered dentures. Dr. Folse. There are I believe eight States with no services at all, and this is from some data that I had about a year ago, so I am doing it by memory. I think we had eight with none and 22 with either limited or emergency only, and the rest of the States had what they considered full coverage for adults. For children, everyone is required to have full coverage. So the heart of this would be taking ``aged, blind, and disabled'' and saying you must cover them also, and that is where ageism comes in to me. We have a vulnerable child population, and we have the same issues on a vulnerable adult population, but we do not have the same requirements. I would love to see that as a requirement. We could increase the FMAP for the States, too, the Federal matching dollars. If we increased that for that program, it would be a really nice thing that would fly politically--with a big question mark. Senator Breaux. I'm not sure what flies politically today. Dr. Davis, what about CMMS? Can you comment on what we have been listening to here? Mr. Davis. The latest number that I have on the number of States that do provide adult dental care is 8 for full benefits, 16 for limited benefits, 18 for emergency-only benefits, and 9 that have no coverage at all. Those are the current numbers right now on the Medicaid side. Senator Breaux. Karen. Ms. Sealander. Karen Sealander with the American Dental Hygienists Association. While there are many inevitable declines in seniors' health, a decline in oral health is preventable, and that is why it is such a tragedy to see Dr. Folse's slides; because if seniors receive regular preventive services, we could prevent all of these horrible oral health tragedies. While the profession of dental hygiene was founded back in 1923 as a school-based profession, over the years, hygienists have lost many outreach opportunities. One solution to the oral health care crisis that ADHA would like to see is increased entry points into the oral health care delivery system. Even seniors who have insurance, whether it is Medicaid or private insurance, often cannot get access to care because they cannot travel to a dental office. So we need to go out and reach these seniors where they are, and ADHA would like to see dental hygienists play an increasingly important role in delivering care to people where they are, whether that be in a nursing home or an assisted living facility. In many States, there are restrictive supervision requirements, but there are some States pioneering less restrictive requirements, and ADHA would like to see that encouraged. Presently 25 States allow hygienists to provide services in nursing homes; 12 States recognize hygienists' ability to provide services to homebound patients; and 10 States recognize hygienists as Medicaid providers. ADHA would like to be part of this solution in a collaborative way. Dental hygienists cannot provide all oral health services--we need to work in conjunction with dentists--but hygienists would like to be able to reach more seniors with our services. Senator Breaux. Let us talk a little bit about that. I do not want to get into a battle between dentists and hygienists, like we have done over the years with psychiatrists and psychologists and chiropractors and medical doctors, et cetera, et cetera. But there are two questions. No. 1, how much help can dental hygienists provide if they were involved in treatment of our elderly citizens, and No. 2, if they can be of help, how many of them would be available considering the shortage of dentists that we have? Can anybody talk to me about how much help they could be? Ms. Sealander. Senator Breaux, with respect to the historic turf battle, there is more than enough unmet need for all of us to play a significant role, so there is really no need to squabble over turf. With respect to the workforce issue, the number of dental hygienists in the workforce has grown steadily and is expected to increase by 37 percent between 2000 and 2010. Dentists, on the other hand, are among the five health professionals with the slowest rate of job growth, a 5.7 percent increase projected between 2000 and 2010. Right now, approximately 5,500 dental hygienists graduate each year and about 4,300 dentists graduate each year. Morever, dental hygienists are educated to care for geriatric patients; geriatric care is a required part of the dental hygiene accreditation standard. Because dental hygienists provide preventive oral health services; and do not provide restorative services, hygienists to work in connection with dentists, and hygienists can serve as a pipeline to dentists. One hygienist in Portland, OR provides services in a nursing home in an onsite dental clinic that was built with donated equipment. She works there one day a week, and then, one day a month, a dentist comes in and provides the needed restorative care. Dr. Folse. They would be an integral part of the team, and I think hygienists are going to be integral in the final solution of this; they are going to be a big part of it. Senator Breaux. Anybody else? Paul, and then Jim. Dr. Glassman. You are touching now on workforce issues, which I think are going to become a major problem. This problem that we are talking about now with elderly and disabled people having difficulty getting access to care is going to get worse because of workforce problems. It certainly is true that the number of hygienists is growing faster than the number of dentists. Dentists who are retiring now went to school at a time when there were 6,000 dentists a year being produced, and they are being replaced by today's 4,000 graduates. The thing I want to point out, though, is in all of the estimates about how critical this workforce shortage is going to be, all those estimates if you look at them carefully are based on an underlying assumption, and that assumption is that those people who are currently left out of the oral health system who do not have access to oral health are going to continue not to have access to oral health. All the analyses on workforce are based on that assumption Senator Breaux. Dr. Harrell. Dr. Harrell. The American Dental Association has consistently studied the workforce issue, and there are some problems with some of the data, and it is hard to project the needs in the future. We recognize the value of hygienists, particularly as Greg said in a team concept, where the dentist does the diagnosis but the hygienists particularly are extremely valuable, I think, on the education end of this thing. I looked the other day, and there are 44 States--our policy in the American Dental Association is that it is sort of a States' issue, but 44 States have chosen to give some laxity of supervision to hygienists in nursing homes. Whether that has increased the care, I do not know. The only concern is that the diagnosis is done so that we do not just polish decay but that we really give treatment. Senator Breaux. Yes. It seems to me that some of these people who are institutionalized, not to mention those who are not in institutions, but all those who are in assisted living facilities or nursing homes, never really have anyone look into their mouths to see what kind of oral health they have. A dental hygienist could certainly help identify serious problems that necessitate a dentist to do the extra work that may be required, but there is an awful lot that could be done just to help identify the problem and help with at least a partial solution to the problem. Dr. Collins. Dr. Collins. Thanks, Senator. Like others, I appreciate the opportunity to be here. For the moment, I would like to make three points. One is about the reimbursement issue, which is obviously a complex one, and you have heard a lot of different statistics about what is covered and what is not covered. The key issue to me is that the service is an optional one regardless of where you are in the United States, so that when times get tough, things that are optional tend to disappear. This is the solution that Greg is offering as an attempt to address that. The second point I want to make is about education and training, looking at alternate solutions--not necessarily training an entire workforce of geriatric specialists--that is probably very impractical, although I would certainly encourage us to have a core of them; certainly we need them as faculty to teach, we need them in programs where they can take referrals for the more difficult, and we need them to educate of general dentists in order to get treatment to these older patients, who yes, may have the same kind of disease, as younger patients but they also have many co-morbid conditions that make it difficult to treat them and that add special conditions that require consideration. In some of the material that was provided in advance of the hearing, it has been reported the dental schools, that have made considerable progress in offering didactic material--in geriatrics nearly all of them do now--but clinical training has lagged behind. I graduated from dental school in Philadelphia in 1971, and there was no geriatrics in my course of study; there was very little public health. Downstairs in a little, obscur room, there was something called a special patients' clinic, and I had an instructor who by chance got me involved in that clinic, and I think it made a big difference in my interest in this area and in public health in general, because you got an opportunity to understand that these people had needs like everybody else, and they were eminently treatable if you had the right skills and you understood that. So that is definitely one of the three legs of the stool. You have to have practitioners who understand that whether they are dentists, whether they are auxiliaries, whether they are hygienists. The third point I want to make is in the area of research. In the Surgeon General's Report, he talks about science being the lead and the connection for us to make progress in this area and many other areas in oral health. I definitely think there are many opportunities, some of them linking the reimbursement and workforce issues, maybe done through the universities, looking at different distributions of personnel and how well they can address problems, whether the elderly patients are in the community or they are in the institutional setting, because in either situation, it is not a matter of one size fits all. We used to make assumptions--and I think that is why there are so many denture programs or priority on dentures--that people were going to lose their teeth, and if they lost all of their teeth, then they were going to need dentures. Our other priority was kids. So we had denture programs, and we had basic programs for kids. Times have changed rapidly as dental insurance has grown. We have people with complex medical problems, but they also have complex dental problems; they are moving into old age, and suddenly, they do not have reimbursement for this care, and as they develop other kinds of co-morbid conditions, they have problems. There is a vast opportunity for us, I think, in the research arena, delivering care in many cases at the same time, to find solutions that use resources wisely--give patients what they need; do not give them more than what they need. Senator Breaux. A good point. Paula. Dr. Friedman. Thank you, Senator. I wanted to point out a workforce issue agenda that is actually interdisciplinary, and it speaks to the need for increased education in oral health across all health care disciplines, and the invisibility, if you will, of oral health care among other health care providers. I brought with me for the purposes of this hearing two publications that just came out. One is a Public Policy and Aging Report produced and published by the Gerontological Society of America called ``Emerging Crisis: The Geriatric Care Workforce,'' which speaks about the dearth of health care providers across all health care professions, except that oral health is not even mentioned here. There is no mention of oral health in this well-respected association's publication on the workforce crisis. The second one is a joint publication by the Merck Institute of Aging and Health, and again, the Gerontological Society of America, called ``The State of Aging and Health in America,'' which again does not mention oral health at all. So I think that when we talk about workforce issues and about increasing awareness of oral health as an important and critical component of overall health, which was mentioned by Surgeon Everett Koop many years ago, it is very important to not only consider the oral health professions but interdisciplinary professions as well. Senator Breaux. That raises a question, Greg, with your slides, and I am sure that any State you go to, you could go to a senior facility and see the same problem, maybe some even worse certainly, maybe some not as bad. But why doesn't a regular medical doctor when doing a normal check on an elderly American--anybody can look into someone's mouth and say look, they have a dental problem. I mean, I could look in there and say this is a dental problem before it got to the point where it got there. You did not need a dentist to tell those folks in your slides that they had a problem long before it got to that point. Do doctors not notice this, or ignore it, or just do not look? Dr. Folse. I have had a lot of interaction with the American Medical Directors' Association. They are the doctors who go into the nursing homes. I teach them about this, and I called it ``the forehead slap''--when you talk about it and they go, ``Oh, my God--I am not even looking.'' I see that time and time again. I call it ``the forehead slap factor,'' and I have it on an additional slide. We have a long way to go in that regard. I think, though, that as we gear up as I have in my area and as other dentists have around the country, when you gear up an oral health program, they start thinking about it. Then, when you have a few patients who have complex problems and you point it out to them, they start looking. But it needs to be part of the normal routine, and it is not right now. Senator Breaux. Teresa. Dr. Dolan. Senator, I had the good fortune as a recent dental graduate to participate in a VA fellowship training program which was multidisciplinary, where I worked with the nurses and physicians and physical and occupational therapists, and we learned from each other. That was one way of sensitizing them to oral health issues that they were probably never exposed to during their usual curricula. Also in the VA, they had dental operatorie in the nursing facility, and we provided preventive and restorative care with dental hygienists, and it was a wonderful model. Over time, those programs disappeared, so we had probably fewer than 30 trained geriatric dentists who had that experience. Senator Breaux. In VA facilities? Dr. Dolan. In VA facilities. Many of those VA trainees are in this room and have become the academic leaders in geriatric dentistry. When I joined the University of Florida, we had a 6-year HRSA training program, also multidisciplinary, with physicians, dentists, and other health care providers, where we learned from each other. Physicians learned about oral health. We learned from physicians about medical complications that were important in dental therapy. Again, those programs were severely cut in Federal budget cuts. I believe that now there are fewer than 10 individuals being trained in those programs. We no longer have a program in the State of Florida. I think models have been tried and have been successful, but they require commitment and resources. I think we do have a lot to learn from each other. If you look at the medical education curriculum right now, there are probably less than 10 total hours of instruction, in a good school, about oral health issues. So I think there are many, many areas that need to be addressed. We have had models in the past that have worked and for one reason or another are no longer funded and supported. Senator Breaux. Yes, Dr. Musher. Dr. Musher. Senator, I am a physician. I am board-certified in family practice, and I am a fellowship-trained geriatrician. I am also a past president of the American Medical Directors' Association, so I was happy to hear comment about that. One of the things that that organization has been trying to do is help educate our medical directors who by law have to be in nursing homes related to the different issues that are important in nursing homes, and one of them is oral care. But I do want to mention in my training as a fellow that I was trained in oral care. I reach a point, just as anyone else, where I would find a problem in oral care and I would need to find a dentist or an oral surgeon to help care for that problem. But I think we are saying two important things here. One is the team approach, and the second part is education. In the nursing homes, we have what is called the minimum dataset, and in part of that, we are supposed to be assessing for oral care and looking in our residents' mouths, our patients' mouths, and assessing for certain problems. I have heard a lot of people have advocate for education, and I think that is critical. I think we have to better educate the staff in the nursing homes all the way down to the CNA level what to look for and then how to plug that patient into the system, and I think they can be educated. They are with the patients every day. They are helping brush their teeth, taking care of their dentures, et cetera, et cetera, so I think that would be important. I think educating physicians to work with dentists and other health professionals is part of that. I think there are a lot of physicians who are still in nursing homes that are not as well-trained or feel as comfortable, if you will, looking in patients mouths. I also wanted to comment that, for example, a lot of the patients we are seeing now in the nursing homes are frail, they are demented, they are a little harder to care for in some of these ways, but there are some simple things besides what we have heard today that I struggle with every day such as xerostomia, which is just a dry mouth, either from medicines or just from the aging process, which has huge repercussions. I have had patients who were going to get gastric feeding tubes because they stopped eating because you need saliva to taste the food. My patients were not tasting the food, and they stopped eating. As soon as that was brought to my attention, I realized it was a dry mouth. That is something simple that anybody could hopefully recognize and correct. So I think it underlines again that more education is critical. I guess one side comment because I also have a private practice, and one of the things that has frustrated me--and maybe it gets to the financial issue a little bit--is that I think if there were less paperwork related to billing issues, maybe the health care system would not be as costly. Senator Breaux. Thanks, Jonathan. Robert. Dr. Klaus. It seems to me and to Oral Health America that there are two chapters in health history in the United States. One is overall health, and then there is oral health. This has contributed to the problems of oral health being perceived in almost abject isolation and what we call almost a militant indifference--and it is not just us. Listen to how the Frameworks Institute, a think tank in Washington, DC., describes the problem. ``You cannot solve a problem that is not perceived to exist by the public. To say that this issue has not emerged in public discourse is to greatly understate the issue. It is invisible.'' I would suggest just looking around the room--and I do not know everybody here--but we are all part of the oral health family, and the solutions to this problem will not be advanced, Senator, until we begin to get outside and get coalitions that speak to this issue as passionately as we do. Senator Breaux. That is a good point. I have always said that in solving problems, first, people have to understand that there is a problem, and after you realize there is a problem, you can talk about possible solutions to the problem. The third part of any program is to convince people that these solutions are worth pursuing and worth investing a financial commitment to help pay for what you think is the right solution. So first, you have got to recognize that there is a problem, and that is what we are trying to do and to try to let more people know that the oral health of our Nation's seniors is a severe problem and is one that can be corrected. Then, we have got to come up with some ideas of what should we be doing. Greg suggested trying to make sure we at least cover aged, blind, and disabled seniors. We could start in that area. Then, you have got to have the political wherewithal to go out and sell that proposal. So it is a three-step process. It is not rocket science, but it takes some commitment on the part of people. Somebody else had a point. Paul, first. Dr. Glassman. Just to extend this discussion about awareness and are people seeing things or not seeing them or ignoring them, I think it is a combination of both. It certainly is a gigantic awareness problem where people look right past the mouth and sometimes do extensive medical tests, workups running to thousands of dollars for somebody and it turns out to be a dental problem. I spent 20 years working in a hospital dental clinic where that would happen time and time again. You would have someone who was in the ICU and had been there for a week and had had all kinds of expensive tests and then finally, in frustration, giving up and saying, ``Let us call a dentist in,'' and you would look, and sure enough, there would be a dental infection, and that was what was causing the problem. I supplied a videotape to your staff of an adult lady who was not verbal and mentally retarded who was admitted to a locked psychiatric facility in California at a cost of $150,000 a year to the State of California because she was exhibit bizarre behaviors and lashing out at people around here. Luckily, there was a dental hygienist in our State who was connected through a program we have who came in and saw her and thought maybe this was a dental problem. Because we have adult benefits in California for this group, they were able to see her, and within 24 hours after dental treatment, she was back to her normal behavior and back living in the community again. That was a pretty dramatic story. So I think we have a giant awareness problem, but I think we also have a giant frustration problem, which is imagine that you are a physician or a social worker or a nurse and you are in a nursing home or working with a group of disabled people, and you look in the mouth and you recognize there is something wrong, and you try to get someone to come in and see that person. How many times are you going to try? You dial the phone, and you call 20 dentists, and after a while, you give up, and you stop looking, and you stop trying to even bother because you know you are not going to get anyone to come in and see them. So we need awareness, and when someone does become aware, we need to have something that they can do that is going to work. Senator Breaux. That is a very dramatic story from a cost standpoint. Dr. Harrell. Senator, we appreciate you taking your time this afternoon, by the way. I want to make two points. I just participated in an Interfaces Conference which dealt with children's dentistry, sponsored by the American Association of Pediatric Dentistry, and they had a group similar to this. The physicians in the group did state pretty overwhelmingly that--I think they would have caught some of the slides that Greg had--but especially a lot of the subtleties of oral health, they were not trained in. In fact, none of the doctors present were. I thought that was interesting. Second, with Dr. Folse and some of the people who are sitting here, we are developing an oral health assessment and survey process for nursing homes, and CMS is reviewing that right now. Basically, we would like to at least have the right questions asked, hoping to raise awareness on oral health needs. Senator Breaux. Tell me about what. What are you all submitting? Dr. Harrell. It is called an oral health assessment and survey. It is for nursing home patients, and the nursing home fills it out. That is being produced right now; CMS I think is reviewing it. Senator Breaux. Do they do that now, or not? Is it a requirement to do that now when a patient enters into a nursing home? Dr. Folse. Yes, yes. In every nursing home chart, there is a health questionnaire called the MDS, and on the MDS are seven different oral health questions, and those questions have a lot of problems. Senator Breaux, you have been instrumental, whether you know it or not, in helping me to expose that at CMS. It was from some of the letters and correspondence that you had with CMS about oral health a few years back; so I had it down to thank you for that, actually. We have submitted the actual new questions that will be in every chart across the country, which are going to be good questions. Senator Breaux. How do they differ from what the existing program requires? Dr. Folse. The existing questions had the four main diseases--oral cancer, tooth-borne gum disease, and prosthetics--all mixed into a bunch of jumbled questions, so when you tried to answer one, you had to look at three different things. We separated out those four areas, and by separating them, we will be able to use some of the national data that we have about cavities and gum disease for the gum disease questions. Also, again because of your efforts at CMS, we did the National Surveyor Training Session about a year and a half ago, where we trained the nursing home inspectors. It was pretty much based on the MDS, and the video from that has been dispersed--there were a lot of responses from our facilities across the country looking at oral health. They got this videotape, and they looked at it because they wanted to know what the surveyors were going to be looking for. We are still pretty deeply involved in it, and special care dentistry has really been teaming up with ADA and CMS to have a real good result with that. Senator Breaux. Can Mr. Davis comment on that? That survey will indicate the potential problem that senior has coming into a nursing home. Dr. Folse. Correct. Senator Breaux. It does not provide any treatment, but it at least recognizes that there is a problem. Dr. Folse. Correct. Senator Breaux. Can you comment on the use of that data? Mr. Davis. That data is collected on each patient, and it is actually collected in the nursing homes. It is expanded now. Dr. Folse spoke recently to a group that CMS participated in. It is a contracting group, and they are looking at this expansion of questions for a minimum dataset for dentistry. That is still under review. It is not finalized yet. But it is an expansion. Senator Breaux. That does not do anything for the patient. It is just sort of let us go to the wreck site and see how many people are hurt. Dr. Folse. Correct. Mr. Davis. Right. Surveyors used that as a part of their review. It is part of the things that they look at. They do look at medical records, and they do have interviews with the patients and with the families and with the staff, and they do have observation. Senator Breaux. Where does that MDS go? Dr. Folse. If somebody has a cavity--the new question says, ``Does the resident have a cavity?'' If they check ``Yes,'' that goes onto the care plan. Once it is on the care plan, they are supposed to refer that patient to a dentist or get appropriate care. That is actually the way that it is supposed to happen now. The problem has been in the actual assessments. We have not had enough training to get those done correctly, and where I found 40 percent of my patients had a ``Yes'' trigger to the gum disease question, we found across the country out of 3.6 million MDS's 0.8 percent that were being triggered. So we were missing 39.2 percent of the population, according to my records. Once that got exposed to CMS, they did make a commitment to us and to you to get the new questions and also to put in a quality indicator for oral health, which means not only will that information be used at the nursing home level; they receive all of those data electronically, and if an individual facility would have, say, greater than 60 percent gum disease, or they would report less than 20 percent gum disease, it would trigger the quality indicator for oral health, which would let the surveyors inspect specifically for oral health issues. Right now, the MDS questions are not tied to a quality indicator, so you can check them all of or you can check none of them off, and no survey question will come because of the MDS questions. So we are changing that. Senator Breaux. My next question was who makes that assessment. When you are admitting someone into a nursing home, is it a registered nurse, a practical nurse? Is it just an administrator who is on duty that night, who takes a look at the patient and says ``Yes'' or ``No''? Dr. Folse. In my facility, it is a range. Some facilities have licensed practical nurses do it; some have RN's do it. I have one facility--I do not go there anymore--where the social director was doing it, which was not that appropriate. Having the training to get them up-to-speed will help. I think the way that we handled that broad case was ``This is normal'' and ``This is abnormal.'' If it is abnormal, you check it, and you refer it. We tried to make it real simple, get out the big dental terms--that is not going to work. The problem with the personnel who are doing it now is that every time they check this stuff off, they have to refer, and there is no infrastructure to refer them to. So it is a round- robin thing. Senator Breaux. Dr. Musher? Mr. Musher. Yes, just a couple of comments. One, I can assure you that the MDS is taken very seriously in the nursing home, but I think it is more of the stick than the carrot is what you are hearing, and it is also data. I think what everybody is saying--and usually in facilities, it is an LPN, licensed practical nurse, not usually RN level, who is filling out this information--it is supposed to point out where we have concerns or problems to then lead into other things. It used to lead into what we called the RAPs, which were resident assessment protocols, or guidelines or other things--in other words, there may be a problem, how do we now approach that. I think that is good, but I think what everybody is saying is that if it just becomes filling out the form and moving on, then we really have not accomplished what we need to accomplish. What we need to do is use that form as a guide, if you will, or a screen to say that we may have some problems, but we need to give the individual, whether it is the nurse or the other individuals in the facility, the education and the means to then go to the next step--because normally, as you are pointing out--and I have been pretty fortunate in most of my facilities to have dentists and dentistry available--but if there is a problem, I usually get the call. You are absolutely right--sometimes it is very frustrating to sit there and say well, I think there may be an abscess or a problem, I know the best treatment for an abscess is to take care of it, not just to treat with antibiotics--how do we then get to the next step? Dr. Folse. I actually as the dental director in my facilities do the MDS for them, and that is one reason why I really like the dental director model, because I am part of that process, I am part of the team. Senator Breaux. Yes, Daniel? Mr. Perry. Thank you, Senator. On one level, obviously, what we are talking about is the deplorable state of oral health in America, especially for our seniors. But just beneath the surface are two threads that are coming together. One is the thread of ageism which is endemic throughout the American health care system at all levels, where older patients tend to get fewer preventive treatments, less screening, fewer interventions than younger people would; and on the other end--and this, too, is part of ageism in our health care--is the failure of our professional health education schools to be able to provide some access to geriatric content for everyone who passes through them. For those on the committee who may not know it, Senator Breaux has taken the leadership on both of these, and you and your staff are to be commended for full-scale hearings within the last 18 months, both on the shortage of academic training in geriatrics and on ageism. I cannot offer today a simple solution to ageism, because it is part of our society; it is part of the fabric of who we are, and it has terrible effects on older people in health care. We ought to bring attention to it as you have been doing, Senator. On the issue of greater envelopment of health professionals in their training in geriatrics, we can do something about that, and I am urging you and your staff to look at what we might do through HRSA to improve professional health education with geriatric content and most promising to create some department-level centers in our academic health centers where not only physicians and nurses and pharmacists, but dentists and all allied health professions, have to rotate and receive some of the basics in good geriatric care before they are out treating a patient population that increasingly is 50 percent age 60 and older in this country. Senator Breaux. I think that is a helpful suggestion, and I think we have heard a number of them. I am trying to figure out, if you had the ability to write a recommendation to the Congress and to the U.S. Senate as to how we can improve the quality of dental care for our Nation's elderly. I have heard the suggestion of the greater use of dental hygienists because of the shortage of dentists in many areas. I have heard the suggestion of trying to increase Medicaid coverage for the aged, blind, and disabled, at least move in that area with a limited amount of money. Are there other suggestions that may be appropriate that we have not put down? Paula. Dr. Friedman. Thank you, Senator. I have four recommendations that, with your permission, I would like to read into the record. ``One, broaden grantee eligibility for geriatric training programs. Dental education institutions currently may only compete for geriatric education center grants. ADEA recommends that grantee criteria be revised to include dental education institutions as the responsible applicant for the geriatric training for physicians, dentists, and behavioral/mental health professionals program. We further recommend that the criteria be broadened so that faculty members employed by U.S. dental schools are eligible to compete for geriatric academic career awards, which are currently limited only to physicians.'' While I certainly agree that we do not need to train a huge cohort of specialists, as you indicated earlier, we need to train enough to, as we call it, train the trainers, so that they can train general dentists and dental students. ``No. 2, authorize a new geriatric dentistry residency training program. ADEA recommends that a new Federal grant program modeled on the general and pediatric dentistry residency programs be authorized by Congress to prepare the dental workforce to meet the growing needs of an aging population.'' This might be a component of an existing general dentistry training program or indeed a second year added onto a 1-year training program in general dentistry with emphasis on geriatrics. ``No. 3, authorize a new NIH loan repayment program for research on the elderly and other special needs populations.'' I think that is self-explanatory. ``No. 4 and finally''--I believe this fourth one encompasses both an access issue and the fiscal piece that we all agree is an important component of geriatric oral health care, and that is ``authorize a new reimbursement program for elderly dental care at academic dental institutions. Dental schools and their satellite clinics provide a significant amount of oral health care to the elderly. We are considered the safety net for people with limited fiscal resources. We cannot expand services beyond what is being done if Federal assistance is not made available to assist in paying for unreimbursed care.'' Dr. Folse talked about the large degree that all dental schools certainly are providing in terms of unreimbursed care. ``ADEA urges Congress to authorize a dental reimbursement program for poor elderly obtaining treatment at the Nation's dental education institutions.'' That certainly could include dental hygiene institutions. For your information, Senator--I imagine you know this, but just for the record--the fees at dental schools are generally a fraction of fees in private offices, so that a relationship with a dental education institution would be by extension a fraction of the cost of a private practice program. Senator Breaux. Those are good suggestions, and we would like to make sure we get a copy of that and the whole presentation. Paul. Dr. Glassman. I think that in addition to funding and training systems, there needs to be a support system, and let me tell you what I mean by that. We are just finishing up now a grant program that we have had in California. We have been working in eight communities around the State where we have had what we call a community- based system that is involved using people that we call dental coordinators. They are mostly dental hygienists, actually, who have played this role. Their role is to actually act as a liaison between the social support agencies that exist in every community that deal with the special populations we are interested in and the dental professionals. They do screening and triage; they get people into dental offices; they entice dentists to be willing to say ``Yes'' when they get a referral. They do preventive education. I will give you an example of how it might work. Let us say you are a dentist, and you have a busy practice, and your practice is pretty full with people who can come in and pay full fare and sit in your chair and do not have a lot of complicated medical problems. So someone calls and says, ``My mother has dementia. Can I bring her in to see you?'' You think, well, things are kind of busy, but sure, I want to do my part. So the person shows up, and you find that the daughter who brings the person in does not really know about their medical history or the medications they are taking, and their behavior is such that there is just no way you are going to treat them, and you spend a frustrating half an hour or 45 minutes trying. The next time you get a call like that, what do you think you are going to say? You are going to say, ``No, I really cannot do that.'' Now picture situation No. 2. You have a dental coordinator in the community who calls up and says, ``I have just done a screening on this individual. I was out to see them. I know your office because I have talked with you before, and I know the kinds of things that you are able to do in your office, and I think this person would work pretty well in your office. When they get there, I am going to make sure that you have all the medical history information you need, and we are going to take care of the consent issues, because I am going to work with the social service agency who knows how to get consent.'' When the person gets there, they are going to have the medical history, the consent is going to be taken care of, they are going to be matched to the dental office. Now, the chances of that referral being successful are infinitely better than the first one. So in that kind of program, our 3-year results are now showing that people have significantly less dental disease. There are numbers of dentists in these communities who are now willing to say yes under the circumstances I just described who were not willing to say yes before. In fact, the amount of dental disease in the population we are talking about, the burden of dental disease, the cost of providing treatment for that dental disease has gone down to a degree that it is more than the salaries that we are paying to these dental hygienists who are providing these services. So I think there needs to be a support system that goes along with funding and training. Senator Breaux. So your suggestion is--are you trying to do this in California, or---- Dr. Glassman. We are just finishing up a 3-year demonstration and demonstrating the effects of this, and we are showing great results. Senator Breaux. So is there a dental coordinator for seniors? Dr. Glassman. We picked eight communities throughout the State. We have a dental coordinator who works with social service agencies in those communities and plays this role of acting as a liaison between these agencies and the dental community, helps to bridge the gap, helps to make the kinds of referrals that we talked about, does preventive education and preventive programs, does screenings and gets people into care. Senator Breaux. A good idea. Jim. Dr. Harrell. The only thing that would worry me is that in North Carolina, we have a shortage of dental hygienists, so I cannot tell you where you are going to get them--do not take them from my office. Also on the manpower issue, as I said, we have studied that, and the term ``shortage'' has been used a couple of times. I do not know--and there again, the data is kind of squirrely--but I do not know that we have a shortage, but we definitely have a maldistribution. I think the Surgeon General mentioned diversity of the dental work force. The University of North Carolina is starting to give preference to students from rural areas, hoping that they will return to rural areas when they graduate, because they tend to go to the metropolitan areas. So it is hard to know, but I do not know that we definitely have a shortage. Senator Breaux. We have had some good suggestions, and this is the first thing that we have ever focused on a particular problem area of seniors in terms of a disease. We have held hearing on senior problems with people who were scamming them from an insurance standpoint, people who discriminate against them in the job market, actual care and treatment that they get in nursing homes, and have looked at alternative means of caring for seniors. But I think this is really the first time we have actually had a discussion on a particular ailment of seniors that has not been noticed as much as it should or treated as adequately as it could be. I think it has been very helpful to do this, because this really is sort of a silent illness out there that people are ignoring, and it leads to much more serious problems, much more expensive problems, and a lot of suffering that in many cases is unnecessary in today's society. The question is how do we go about trying to fix it and how do we go about trying to solve it. We have gotten some good suggestions on the table, and I would like to see if anybody has any closing comments, perhaps, to help us summarize. I want to try to bring the information we get from here to maybe do some statements on the floor of the Senate to try to get some other Members interested in this, because when you find out that most States are not doing a very good job of paying attention to the oral health of our Nation's seniors within their States, it is a serious problem, and it should not go neglected as we have neglected it in the past. Does anybody have any final suggestions that may be helpful? Robert. Dr. Collins. Thanks, Senator. This has been a wonderful hearing. There is an awful lot of information that is out there, and many people around this table and others have had an opportunity to contribute to that. I think this is one more step in the Surgeon General's Call to Action booklet which he kind of modestly talked about today, but I think is increasing the involvement of a larger community of people. I had a mentor as I came along in public health who used to talk about ERAs of expectation in regard to oral health. The first one, which I guess covers a large portion of history, was resignation. You had pain, and you just found out a way to deal with it, and maybe you had somebody who could relieve it by knocking your tooth out. We went into a second period of rehabilitation where you had dentures available, crude in the beginning, more sophisticated as time went on, where people could still expect to lose all their teeth, but now they had some sort of replacement. The third era, which we are really still in and coming out of as a whole is the restorative area. These are the 77 million that you are talking about in your question, people who have a lot of complex dentistry who are moving into older age. The final era is one of prevention. So, we have some conflicts here with people who are in an era where they are beginning to expect that a lot of these problems that Dr. Folse so nicely illustrated today should not be there--they should be prevented. We have research that can go a long way toward pointing the way to do that, yet we have a system that I would say in many cases is not even in rehabilitation in terms of responding; it is back in resignation. So there are lots of ways that we can point forward to the future, and I just wanted to underscore my appreciation and support not only for what the Surgeon General is doing, because I think that is a terrific, terrific booklet, that little green booklet, but also for all the Federal agencies, in particular the National Institute of Dental and Cranio-Facial Research-- yes, it does support a lot of research in universities and across the country and funds most of the dental research and is therefore very important, but it also serves as probably the principal coordinating center in the Federal infrastructure for oral health and makes it possible, I would say, probably if you go back to the beginning, possible for all of us to be here today. Thank you. Senator Breaux. Thank you. Ms. Heinrich, do you have anything from General Accounting? Ms. Heinrich. I really do appreciate the opportunity to hear all of these ideas. It really is very thought-provoking. I appreciate your point that there are several ways of focusing on this problem, and one question I had was with the focus that we have put on prevention with children-- fluoridation, for example--do we anticipate that this problem is going to wane in the future? A second question--Paul, you have talked about some best practices in California; there might be some in New York also, since they got a C-plus--but has there been any effort to identify strategies that really do work in trying to bring better dental care to older populations? Senator Breaux. Let me interrupt. I am going to have to take off. But Janet, why don't you all finish up on this question, and let me just conclude for my part and thank each and every one of you. I think it has been very important, and we have gotten some good ideas. To those who have travelled, thank you, Greg and others who have come from other places, for being with us. It was well worth your effort as far as I am concerned. I am very appreciative of the information that we have been able to learn and the suggestions that we have received. So I thank you all, and please continue. Dr. Folse. Before you leave, we thank you very much. [Applause.] Dr. Glassman. Just to respond to the question about best practices, yes, I think there are a number of publications and articles and lots of information about best practices. The problem is that the best practices, the theoretical ones, the ones that have been used in demonstration projects, are not widely available and not widely used because of the issues we have already identified here--awareness and funding and training. So the best practices do exist. The American Association of Geriatric Dentists has a number of publications about guidelines for nursing home dental practice. There are guidelines in other areas. The next issue of the Journal of Special Care Dentistry is going to have the results of an expert panel that we brought together to look at prevention in disabled and elderly populations. So I think the information is there. The problem is taking that information and translating it and getting it into practice is where there is a gigantic chasm. Ms. Heinrich. In terms of Senator Breaux' interest in having material that people could speak to, are there some of those that would have information about dollar savings or costs that could be provided to Members of Congress? Dr. Glassman. I am not aware of that. I do not know if others are. Dr. Collins. I pointed out earlier that one of the things in the Surgeon General's report on Oral Health in America is that it states in that report the lack of data about both the oral health burden and strategies and all those things, and we all wish we had numbers about those kinds of things. The numbers are generally not available, unfortunately. Dr. Folse. Dr. Barsley actually did a study in Louisiana for Medicaid children where they used some interventions, and there were significant savings with just water fluoridation for that population. Dr. Barsley. Dr. Barsley. For children with fluoridation, we showed the parishes or counties that were fluoridated had significant savings over the counties that were not. Does that translate to the adult population? I am not sure. I would break in and answer one question--I do not see this problem waning at all. As people have better teeth and better lives, we are going to have a bigger problem. So I do not see any waning of the problem in any way at all; it will just continue to grow. Ms. Heinrich. Paul, and then James. Dr. Glassman. I just want to emphasize that point, that the problem is not going away. We have gone from in our country 20 years ago, I think it was something like 56 percent of people over 65 being in dentures; now it is down to about 26 and dropping. So we are having more and more seniors who are becoming seniors with teeth that did not used to have that, and the fact that disease for certain groups of children is going away does not really have much impact on what happens when people get to be 65 and can no longer care for themselves the way they used to and begin to take medications and have dry mouth. So I think this is going to be a blossoming problem. Ms. Heinrich. Teresa. Dr. Dolan. I would just add that I certainly agree that this problem will not go away. It is a good news/bad news story, because as the younger cohorts of adults age, and we have retained their natural teeth--maybe we have had some dental fillings--but we also have higher expectations, and we are more vocal about our expectations, I think as those folks become chronically ill and perhaps end up in long-term care facilities, the demand for a more appropriate level of oral health services will grow, and if anything, the cost associated with that will increase. I think that what is currently a silent epidemic will become more prominent. Ms. Heinrich. Go ahead, James. Dr. Harrell. As we have a unique program in North Carolina, I will try to get any data on cost-sharing that the ADA has for you. I am not sure what we have. We do have an interesting program in North Carolina where we have physicians apply fluoride varnishes. We are doing studies on that, and I do not know the results at this point or whether that will be a cost saving or not; we suspect that it will. The problem was that by the time these children were seeing a dentist at 2 or 3 years of age, they already had decay. The American Dental Association has been sort of reeling with the punches and doing what we can to boost the Medicaid reimbursements or whatever. We are having a Medicaid symposium in December, which will hopefully be a small group similar to this one, to actually look at the whole system and maybe come up with some innovations for that system. Also, thinking about Paul's remarks, we have a van program which is mostly a nonprofit organization in North Carolina, but I do not want us to overlook the fact that there are multi- millionaires in nursing homes who cannot get care because they have special needs, and they require treatment that they do not have the facilities to do--even if they can bring them to my office, I cannot do it. So I do not want us to overlook that segment of the population either. Ms. Heinrich. Senator Breaux was beginning to ask all of you for recommendations on solutions to this problem, and not all of you had a chance to speak, so I would ask if there are other ideas. Mr. Musher. Just a couple of points--I guess some things that we could do now, not to lighten the big, 10,000-foot view--but there are certain initiatives going on now. For example, there is a pain initiative. There is a collaborative initiative that CMS is part of concerning pain and trying to develop best practices. Certainly oral pain problems and syndromes could be better focused on through that. So I think there are certain programs that are going on. The American Medical Directors' Association has created many guidelines. That could certainly be something that would lend itself toward a guideline on how do you approach oral care in the nursing home. Again, not lightening the access to care, which is what I hear is a huge issue, and my frustration, as I mentioned earlier, is trying to get a dentist or a dental surgeon or extractions or certain things that I may need at some points in time, but I think there are areas where we could use some of the systems or some of the approaches that are now available to just better point out the need for oral care. I know that like no other industry--in the nursing home, if you focus on something, there is a very good likelihood of it happening, especially when you connect it with MDS and other survey issues. But I think that a lot of what I am seeing is if we could just get the word out that oral care is something that is urgent and important, just like we did several years ago with restraint reduction--there was a huge decrease in restraints once we put it back on the providers of services to say this is a huge problem, we need to work together to solve that problem--and we did, and I do not think there was a huge cost to that. So although there are a lot of costs and issues that we have talked about that I don't think lend themselves to that, I do think at least some focus on how we would approach oral care in nursing homes is important. The other point I would like to make--and it is no different from what we struggle with in other parts of medicine with our population, and I will use high cholesterol as an example. We do not treat everybody who has high cholesterol in the nursing home population because it is risk-benefit and it is quality of life issues. So at some points, I think we also have to look at what should we be treating and what do we not necessarily have to treat. The Senator mentioned earlier about whitening teeth. I am not really worried about cosmetic issues in a lot of my patients. I am not sure--and I would defer to my dental colleagues--whether I have to worry so much about dentures, because I was taught that a lot of my patients could actually gum their food. So I am not sure that dentures are as important as pain, abscess, xerostomia, which I have seen huge problems with. So how do we focus--the pain, the abscess, those kinds of things in my severely demented patients are a quality of life issue, so I would want to focus on the quality of life issue, but I think we have to break down the population, because the nursing home has dementia and end-stage and almost palliative types of care, but there are all other subsets of elderly in our population. Ms. Heinrich. Yes? Dr. Barsley. If I could add one thing that I do not think has been addressed, or only on the margins, it would be to increase interaction and educational interplay between physicians and dentists. I used to teach at the medical school and give lectures on dental health to medical students. They were amazed at what we brought them. Then we would bring them out to our clinic and have them actually look into each other's mouths, and they were further amazed by what was in the mouth besides the teeth. So I think if we start at an early time and broaden that, we would be benefited. Ms. Heinrich. Karen. Ms. Sealander. I think that the mere holding of this forum is an important signal that this committee, and hopefully the whole Senate, thinks that oral health is important. Hopefully in the future, whenever Senators think of seniors' general health, they will think of oral health as well. We know how to prevent the principal oral maladies, and despite this proven prevention capacity, we still have this silent epidemic of oral disease which disproportionately affects our vulnerable citizens, particularly the elderly. ADH wants to be part of a collaborative solution to the problem of oral health disparities and inadequate access to care. ADHA believes that with the increasing number of hygienists, the occupational growth, and with our focus on prevention that dental hygienists are well-situated to play an important role. One specific suggestion that ADHA offers is to ask the committee to direct CMS to write to State dental directors, asking them to facilitate the provision of Medicaid oral health services by hygienists, specifically to recognize hygienists as Medicaid providers of oral health services. Ten States already do recognize hygienists as Medical providers and ADHA would like to see the other 40 States follow suit. Ms. Heinrich. Anyone else? Dr. Folse. A couple of comments in closing for me. In nursing facilities, I think there is an obvious partner there. Some of the efforts that we have made have been along survey issues, and I just want to assure you that that is not my focus in my advocacy efforts and the work that I do with ADA and special care dentistry. It is not about coming in with the hammer; it is about we had that opportunity, so you go there. But at the same time, we are doing all kinds of things to help bring that industry up with oral health, working with the American Medical Director Association. I and special care dentistry for sure are seriously committed to working with your industry trying to help in any way that we can. We have education programs all day long that we can help you with. Your point about not treating everyone is really well- taken. I have patients with really bad oral conditions who, because of the risk-benefit issues, I say we are not going to be able to take care of these patients. So I am with you there--education--we can all come to consensus with that. Again going back to a foundation medically is the medical necessity of oral services. I still think it is a medical necessity. Does anyone have disagreement with that? [No response.] So one of the things that we could say from this forum--or can we--is that we were all in agreement that oral health services for vulnerable adults was medically necessary. Are there any nays? I do not see any. OK. My dad was an auctioneer. Dr. Harrell. Actually, I would modify that and leave out the ``vulnerable adults.'' Oral health care is essentially the general health for anybody. Dr. Folse. Thank you. I limit myself unnecessarily sometimes. I think in these State budgetary woes that everybody has, if they would find their State problem and find some things that they did not want to pay for, all they have to do is put a set of lips on it. Once you get behind some lips, it does not get any money, so it seems like it would help somewhere along the way. Personally, I have been involved with this forum, and we have to thank Lauren Fuller who behind the scenes has done an awful lot of work for the last 3 or 4 months, has taken endless calls from Dr. Greg Folse--she probably does not want to hear from me for 6 months, and even then, I am not sure--but we really thank you for your work and your dedication to oral health for elders across the country. You have started something here, and it is going to be a fun ball to watch. Before I let you close this, I want to thank each and every one of you again for being here and participating, and those of you in the audience who really care about oral health services for our elderly, I thank you for being here also. Ms. Heinrich. Well, I think you did a very nice job of closing. I think it is easy to say that you have put information together in one place, and yes, it is going to be interesting to see how this moves forward. Thank you all. 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