Bulletin of Dental Education

What Lies Ahead for Health Reform

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By Nicole Fauteux

At this year’s 2013 ADEA Annual Session & Exhibition, Peter Damiano, D.D.S., Director of the Public Policy Center and Professor at the University of Iowa College of Dentistry, discussed the Patient Protection and Affordable Care Act (ACA) and its long-term implications for dental education and dentistry. He described the ACA as a market-based reform that will drive a substantial majority of the 16% of Americans who are currently uninsured into the private insurance market. He enumerated many of the 50 ACA policies already in place and then talked about what might lie ahead if the bill is implemented as planned, emphasizing those provisions of particular interest to the dental education community.

Last year’s Supreme Court ruling that the ACA’s mandate requiring individuals to acquire insurance coverage or pay a penalty is constitutional means that the individual mandate will go into effect, and health insurance exchanges or insurance markets will begin to operate in 2014. Health insurance policies for sale through the exchanges must include certain essential benefits, including oral health benefits for children, and millions more children will become eligible for care through the expansion of Medicaid coverage. Interestingly, many of the states that raised legal challenges to the Medicaid expansion have since decided to extend their Medicaid programs using federal dollars provided by the law even though the Supreme Court ruled that they could opt out.

Of special interest to the oral health community, the ACA requires that state health insurance exchanges offer a stand-alone dental insurance plan, but states may or may not require their residents to purchase it. This flexibility may mean that only those people who need substantial dental work will purchase the insurance while healthier people will not.

“Allowing too much variation among the states will lead to inefficiencies,” Dr. Damiano points out. He believes the ACA probably does not include enough mandates to achieve its three goals: extending access, improving quality, and lowering costs. Indeed, Dr. Damiano made clear that the ACA is no panacea.

“Americans invest 90% of their health care dollars in the health care delivery system,” he says, “but that system only determines about 10% of our health. The environment, human biology, and especially lifestyle factors are much bigger determinants.”

Although the legislation does less to address these factors, it does not ignore them entirely. It contains a number of provisions, not related to insurance, with potential to improve oral health. These include:

  • A five-year national public education campaign for prevention of oral diseases.
  • The expansion of school-based dental sealant programs.
  • Training grants in general, pediatric, and public health dentistry.
  • Cooperative agreements with the Centers for Disease Control and Prevention to improve the oral health infrastructure of states and territories.
  • A demonstration project for alternative dental health care providers.
  • Improved oral health surveillance.

To date, these provisions have not been funded.

Of equal importance to dentistry in the long run are provisions of the law that will create major shifts in how the health care delivery system is organized. Dr. Damiano singled out Accountable Care Organizations (ACOs) as likely to have a bigger impact on the health care system than other provisions of the legislation. The Centers for Medicare & Medicaid Services defines ACOs as groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated, high-quality care to their Medicare patients. The goal of ACOs is to improve the quality of care patients receive and save money in the process by reducing hospitalizations.

Private insurers and Medicaid are also encouraging care coordination and accountability for health outcomes through the formation of ACOs. Although few if any current ACOs include dentistry, they may in the future. Dr. Damiano noted that this could bring pay-for-performance or risk-based contracting to dentistry.

He also touched on the potential impacts on dentistry of the primary care medical or health homes, the eventual widespread use of electronic health records, and the continuing need for safety-net providers. How will these developments impact dental education?

Dental schools will have to educate their students to understand how electronic health records will be used to assess the quality of care and acquaint students with reimbursement structures that factor in value. Schools will also need to train students to work with other health professionals, including alternative providers of oral health care, so they can function well in the health home and other collaborative work environments.

An attentive audience soaked in Dr. Damiano’s presentation and followed up with questions about corporate dentistry, end-of-life care, the sequester’s potential impact, and the relationship between diagnostic codes and quality indicators. The opportunity to hear such a clear presentation of a topic that can be extremely difficult to grasp was greatly appreciated by those in attendance.


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