1. Maryland Oral Health Reforms: Progress in the Face of Tragedy Maryland Oral Health Summit October 20, 2011 Dr. Harry Goodman Director, Maryland Office of Oral Health

2. Importance of Oral Health U.S. Third National Health and Nutrition Examination Survey 1988-1994

3. Importance of Oral Health They are “just baby teeth”, but this damage can be permanent…..  Cause permanent damage to their adult successors  Inhibit nutrition and physical development  Keep a child up at night  Affect the child’s ability to concentrate and learn in school

4. Importance of Oral Health Pictures Tell a Thousand Stories But if this doesn’t grab you…

5. …Will This? The Death of Deamonte Driver  12-year Maryland boy from PG County  Never complained/no one was looking  Untreated dental infection resulted in 2 brain surgeries, seizures, 1 tooth extracted, and spent 6 weeks in a hospital at a cost of $250,000 Medicaid cost of simple extraction - <$100 and preventive services - <$60 - $80/year Medicaid cost of simple extraction - <$100 and preventive services - <$60 - $80/year  Died unexpectedly-February 25, 2007  Lacked access to treatment and education and prevention services

6. “We can't solve problems by using the same kind of thinking we used when we created them.” Albert Einstein “So when a good idea comes, you know, part of my job is to move it around, just see what different people think, get people talking about it, argue with people about it, get ideas moving among that group of 100 people, get different people together to explore different aspects of it quietly, and, you know – just explore things.” Steve Jobs

7. MARYLAND HISTORY: IN SEARCH OF A DENTAL HOME  Proud history: Robust Medicaid dental program until the 1970’s Robust Medicaid dental program until the 1970’s Early implementation of water fluoridation Early implementation of water fluoridation  99.8% of Maryland residents on public water systems receive fluoridated water (4, 839,490 people)  99.8% of Maryland residents on public water systems receive fluoridated water (4, 839,490 people) – CDC  Ranked #1 in U.S.

8. MARYLAND HISTORY: IN SEARCH OF A DENTAL HOME  Not so proud history: Since the 1970’s, nominal emphasis on oral health Since the 1970’s, nominal emphasis on oral health Poorly supported Office of Oral Health – continually cut Poorly supported Office of Oral Health – continually cut Only half of Maryland jurisdictions with public health (safety net) dental services Only half of Maryland jurisdictions with public health (safety net) dental services 1997–Medicaid managed care arrived with policy to withdraw State funding from county dental clinics 1997–Medicaid managed care arrived with policy to withdraw State funding from county dental clinics No partnerships/No oral health advocacy No partnerships/No oral health advocacy Late 1990’s, Maryland reported to have lowest access to Medicaid oral health services in U.S. Late 1990’s, Maryland reported to have lowest access to Medicaid oral health services in U.S.

9. MARYLAND’S EXPERIENCE: Planting the Seeds (1998 – 2007)  Oral Health Advisory Committee: Government agencies, organizations from professional dentistry, academia, child advocacy, managed care, and public health Government agencies, organizations from professional dentistry, academia, child advocacy, managed care, and public health Advocacy efforts Advocacy efforts Mostly focused on access to care Mostly focused on access to care Networking Networking  Legislation – State Senator Lawlah  Surveillance MCHB/Dental School Survey – Dr. Rossetti MCHB/Dental School Survey – Dr. Rossetti HRSA SOCHS Grant HRSA SOCHS Grant  Early 5-year Oral Health Plan

10. ADVOCACY and PARTNERSHIPS BEGIN: Legislation  Medicaid Reforms (SB 590 - 1998)  Medicaid Utilization Targets  Increased Medicaid Funding  Oral Health Advisory Committee  Dental Loan Assistance Repayment Program (2000)  Pediatric Dental Fellowship Program (2001)  Oral Cancer Prevention Program (2002)  Increased HealthChoice MCO Dental Rates (2003)  Oral Health Safety Net (2007)

11. DENTAL ACTION COMMITTEE (DAC) Oral Health Access Reforms in the Face of Tragedy  February 2007 – Death of Deamonte Driver  June 2007 - Convened by DHMH Secretary Colmers after death of Deamonte Driver  September 2007 – DAC report 7 primary recommendations 7 primary recommendations  October 2007 – All DAC recommendations supported by DHMH Secretary and Governor  April 2008 - Governor’s DAC budget initiatives and other DAC-related legislation passed and signed into law

12. DAC Recommendations and Progress Focus Mainly on Access to Care 1.Statewide single Medicaid dental vendor – July 2009 Maryland Healthy Smiles Program (Medicaid dental program) – DentaQuest Maryland Healthy Smiles Program (Medicaid dental program) – DentaQuest Eased bureaucratic, paperwork, credentialing issues Eased bureaucratic, paperwork, credentialing issues 2.Over three years, increase dental rates to ADA 50 th percentile - 1 st year of increase started July 1, 2008 All preventive, most diagnostic, other procedures All preventive, most diagnostic, other procedures Additional increases delayed due to state budget deficit Additional increases delayed due to state budget deficit Approximately 400 new dentists have joined Maryland Healthy Smiles Program since July 2009 Approximately 400 new dentists have joined Maryland Healthy Smiles Program since July 2009 More pediatric dentists now participate More pediatric dentists now participate

13. DAC Recommendations and Progress 3.Begin to restore dental public health infrastructure  New/expanded dental clinical and school-based/linked public health programs – also dental van  By April 1, 2011, residents in every Maryland jurisdiction now have access to a dental public health program  Deamonte Driver Dental Van Project 4.Create public health dental hygienist  Legislation passed 2008  Being implemented in many public health programs 5.Institute school-based oral health screenings  MDAC Kaiser Foundation grant for pilot project – Sept. 2011

14. DAC Recommendations and Progress 6. Train general dentists in pediatric dental care  550 trained 6a. Train pediatricians, family physicians, and nurse practitioners for oral health assessments and apply fluoride varnish  Integrate oral health into routine primary care practice for 9mo – 3 yr olds as part of EPSDT well child visits  Receive Medicaid fluoride varnish reimbursement – 7/2009 Over 400 trained/Over 30,000 medical claims to date Over 400 trained/Over 30,000 medical claims to date 7.Oral Health Literacy Campaign  Federal grant thanks to Maryland Congressional Delegation

15. Oral Health Literacy Campaign – Spring 2012  Leading the way in oral health literacy taking its cue from the Institute of Medicine (IOM) oral health report  Educate low income families about the importance of oral health and its effects on overall health and well-being Targets pregnant women and children ages 0-6 Targets pregnant women and children ages 0-6 Encourage the public to request and keep dental appointments and be better able to navigate the oral health delivery system Encourage the public to request and keep dental appointments and be better able to navigate the oral health delivery system Empower the public to enhance oral health behaviors such as proper oral hygiene practices and nutritional choices at home Empower the public to enhance oral health behaviors such as proper oral hygiene practices and nutritional choices at home  Need to evaluate campaign effectiveness  Need to develop strategies and expand to other age groups and health care providers

16. Maryland Oral Disease Prevention Program  5-Year Cooperative Agreement (2008-2013):  Infrastructure  Data and Surveillance  State Oral Health Plan  Partnerships and Coalitions  Prevention Activities  Policy Development  Evaluation  Collaborations CDC State-Based Oral Disease Prevention Program

17. Dentists Participating in Medicaid Maryland: 2009/2010

18. Percentage of Children Enrolled in HealthChoice who had at Least One Dental Encounter by Age Group, Enrolled for Any Period Age Group CY 2005 CY 2006 CY 2007 CY 2008 CY 2009 0-37.8%7.9%10.0%12.3%18.6% 4-537.7%37.2%42.4%47.7%56.0% 6-942.5%42.3%47.6%53.1%60.7% 10-1439.4%39.5%44.2%48.8%56.4% 15-1832.4%32.3%35.8%39.5%46.0% 19-2019.0%18.4%20.1%23.4%30.1% Total29.6%29.3%32.9%36.7%43.8%

19. Number of Children Receiving Dental Services Children ages 4-20, Enrolled for at least 320 days (HEDIS) Year Total Number of Enrollees Enrollees Receiving One or More Dental ServicesPercentReceivingServicesHEDISNationalMedicaidAverage FY 1997 88,63817,63719.9% CY 1999 122,75631,74225.9% 36.41 % CY 2000 132,39938,05628.7% 40.34 % CY 2001 142,98848,06633.6% 37.4 % CY 2002 194,35167,02934.5% 39.0 % CY 2003 203,82688,11043.2% 39.4 % CY 2004 213,23493,15443.7% 42.7 % CY 2005 227,572104,18845.8% 41.0 % CY 2006 223,936103,56146.2% 42.5 % CY 2007 216,885111,79151.5% 43.5 % CY 2008 243,076135,40355.7%44.2% CY 2009 254,811150,27559.0%N/A

20. Maryland Dental Action Coalition (MDAC)  Conversion from government charged Committee (DAC) to an independent Coalition (MDAC)  Funding from: Office of Oral Health Office of Oral Health  CDC State State-Based Oral Disease Prevention Cooperative Agreement DentaQuest Foundation DentaQuest Foundation  Many accomplishments  A true partner in every sense of the word

21. Thanks and Acknowledgements Making Good Music Making Good Music Together – the Value of Partnerships “Being in a band is always a compromise. Provided that the balance is good, what you lose in compromise, you gain by collaboration.” “Being in a band is always a compromise. Provided that the balance is good, what you lose in compromise, you gain by collaboration.” Mike Rutherford (Genesis)

22. Congratulations! OOH Staffer Ms. Chris Leo, RDH Winner of the Maryland Rural Health Association Winner of the Maryland Rural Health Association “2011 Outstanding Rural Health Practitioner Award”

23. Progress and Recognition… PEW Dental Health “Report Card”: Maryland received an "A" grade and was determined to be the top performer in the country for dental health

24. …But We’re Not “There” by Any Stretch  Challenges Maintaining our current momentum Maintaining our current momentum Expanding statewide prevention programs Expanding statewide prevention programs Providing a dental home for all Marylanders: Providing a dental home for all Marylanders:  Adults and senior citizens  Special needs children and adults Integration of oral health with overall health system services Integration of oral health with overall health system services Expanding Oral Health Literacy Campaign to other age groups\healthcare workforce Expanding Oral Health Literacy Campaign to other age groups\healthcare workforce Having a truly oral health literate populace Having a truly oral health literate populace Countering anti-fluoridation efforts Countering anti-fluoridation efforts

25. But Together – We Can Continue Our Progress! Still Awake? (my always inspired boys) hgoodman@dhmh.state.md.us (410) 767-5942