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5
A New Oral Health Initiative
The U.S. Department of Health and Human Service’s (HHS’) commit-
ment to improving the oral health of the nation has fluctuated; while there
have been notable successes, these efforts have not led to oral health par-
ity in health care overall. Substantial inequities remain across population
subgroups, and many Americans continue to suffer from avoidable and
treatable oral diseases. The expressed intent of the surgeon general’s report
Oral Health in America was “to alert Americans to the full meaning of
oral health and its importance in relation to general health and well-being”
(HHS, 2000). Now, more than a decade later, scientific investments dem-
onstrate significant dividends in some areas and some progress in children’s
oral health has been made; yet many of the concerns raised in that report
remain (Mertz and Mouradian, 2009; Mouradian et al., 2009; Slayton and
Slavkin, 2009).
LEARNING FROM THE PAST
Through extensive research, testimony, and their own professional
experiences, the members of the Institute of Medicine (IOM) Committee
on an Oral Health Initiative considered why prioritization of oral health
continues to be a challenge in HHS. In any initiative to improve oral health
and oral health care, HHS’ challenge will be to marshal its resources in a
way that produces a significant impact in the lives of people all across the
country. Given that HHS’ resources are limited, the scope of the challenge
is substantial, and many solutions will require the involvement of multiple
207
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208 ADVANCING ORAL HEALTH IN AMERICA
stakeholders, one of the most important roles HHS can play is in providing
leadership and direction for the rest of the country.
The 2000 surgeon general’s report (HHS, 2000) presented the state of
the science in oral health, called attention to the oral health care challenge
facing the country, and outlined a framework for future action. While the
report is still widely discussed today, it did not lead to a direct and immedi-
ate change in the government’s approach to oral health. This disappointing
outcome may have been due to broader environmental factors, including
grave and immediate national crises (e.g., 9/11, Hurricane Katrina); changes
in the economy that affect state and federal budgets (e.g., recessions); com-
peting health policy priorities (e.g., obesity); a tendency to blame individual
behaviors alone for poor oral health; a lack of political will; or simply the
long-standing failure to recognize oral health as an integral part of overall
health. But certainly part of the explanation lies in “gaps in leadership
and the failure to unite a critical mass of key stakeholders with sufficient
common interests, political will, and resources to effect fundamental pol-
icy change” (Crall, 2009). Within HHS, changes in administrations (with
concomitant changes in priorities), workforce turnover (including agency
administrators), lack of oral health “champions,” insufficient funding and
staffing, and the lack of oral health parity may all have contributed to the
disappointing results.
THE NEW ORAL HEALTH INITIATIVE
As was discussed in Chapter 1, this committee was challenged by a
statement of task that called for them to devise a “potential” oral health
initiative, and then the subsequent announcement of the Oral Health Initia-
tive 2010 (OHI 2010). The committee was mindful of the existence of the
OHI 2010 but did not let its existence limit its considerations of what such
an initiative should be. Therefore, in the rest of this chapter, the commit-
tee outlines seven recommendations that as a whole comprise what will be
referred to as the new Oral Health Initiative (NOHI) (to distinguish it from
and build upon the current initiative). In considering a potential HHS oral
health initiative, the committee developed a set of organizing principles (see
Box 5-1) based on areas in greatest need of attention as well as approaches
that have the most potential for creating improvements. It will be HHS’
responsibility to adapt the current structure of the OHI 2010 to these prin-
ciples and the recommendations that follow.
The committee concluded that these principles will help move the na-
tion toward achieving the goals and objectives set by Healthy People 2020,
which represents the best long-term set of benchmarks for judging the suc-
cess of the NOHI. Healthy People 2020 is an existing and well-accepted
set of benchmarks for the country developed by a strong collaboration of
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A NEW ORAL HEALTH INITIATIVE
B OX 5-1
Organizing Principles for a New Oral Health Initiative
1. Establish high-level accountability.
2. Emphasize disease prevention and oral health promotion.
3. Improve oral health literacy and cultural competence.
4. Reduce oral health disparities.
5. Explore new models for payment and delivery of care.
6. Enhance the role of nondental health care professionals.
7. Expand oral health research, and improve data collection.
8. Promote collaboration among private and public stakeholders.
9. Measure progress toward short-term and long-term goals and
objectives.
10. Advance the goals and objectives of Healthy People 2020.
partners. The committee suggests that creating a new set of long-term goals
would only contribute to the redundancy and fragmentation that is often
criticized regarding government programming. In essence, attainment of
Healthy People 2020 goals and objectives is the continuing mission of the
NOHI. The committee further notes that this approach should not be lim-
ited to the goals and objectives of the oral health section, but it also should
embrace the goals and objectives of the health communication and health
information technology section of Healthy People 2020.
Building upon Healthy People gives the NOHI a framework for sus-
tainability as well as the ability to change goals and objectives depending
upon achievements in improving oral health. More importantly, as better
measures of quality in oral health are developed, more sophisticated goals
can be set. The committee also notes that shorter-term and intermediate
goals and objectives will also be needed along the way toward these larger
goals.
Establishing High-Level Accountability
All Americans, especially those from vulnerable and underserved popu-
lations, are at risk of suffering compromised health. This is particularly
important because HHS describes itself as “the United States government’s
principal agency for protecting the health of all Americans and providing
essential human services, especially for those who are least able to help
themselves” (HHS, 2010a).
The committee concluded that previous HHS efforts to improve oral
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210 ADVANCING ORAL HEALTH IN AMERICA
health have largely suffered from lack of high-level accountability, a lack
of coordination among HHS agencies, a lack of resources, and a lack of
sustained interest. Considering the impact of oral diseases and disorders on
the nation, its relevance to every American, and the importance of strong,
accountable leadership, the committee recommends:
RECOMMENDATION 1: The secretary of HHS should give the
leader(s) of the new Oral Health Initiative (NOHI) the authority and
resources needed to successfully integrate oral health into the plan-
ning, programming, policies, and research that occur across all HHS
programs and agencies:
• Each agency within HHS that has a role in oral health should
provide an annual plan for how it will integrate oral health into
existing programs within the first year.
• Each agency should identify specific opportunities for public-
private partnerships and collaborating with other agencies inside
and outside HHS.
• The leader(s) of the NOHI should coordinate, review, and imple-
ment these plans.
• The leaders(s) of the NOHI should incorporate patient and con-
sumer input into the design and implementation of the NOHI.
The identification of specific leadership for the NOHI would create a
robust level of accountability. Because there was not enough evidence to
determine exactly who the leader(s) of the NOHI should be, the committee
concluded that the secretary should ultimately determine the leader of the
NOHI; presumably this could be the current co-leads, the head of the Oral
Health Coordinating Committee (OHCC), a new office or officer dedicated
to oral health, or another person who is given distinct authority. In any
case, as discussed earlier, lack of strong and consistent leadership, insuffi-
cient funding, and inadequate staffing all contributed to the ineffectiveness
of previous efforts. Therefore, the committee recommends the named leader
be given enough authority and resources to carry out his or her duties. If
this effort is to be led by the OHCC, then clearly financial support will be
needed where it currently has none.
Toward the goal of fully integrating oral health into overall health,
instead of merely listing existing or planned oral health activities, the com-
mittee recommends that each relevant operating and staff division provide
clear directions and goals for integrating oral health into all of its relevant
programs within the first year of the NOHI. Aside from their individual
abilities, each division should look for clear opportunities to partner with
other entities, both within and outside of HHS. The committee urges that
these individual plans focus on the issues laid out in the framework for the
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A NEW ORAL HEALTH INITIATIVE
NOHI and include measurable objectives. These objectives could focus on
shorter-term or intermediate measures of departmental performance such
as implementation of new programs and collaborations or demonstrated
impact on oral health status and access. The leader(s) of the NOHI would
be responsible for oversight of all of these plans, including looking for
overarching areas for collaboration and learning both within HHS and
with external partners.
Finally, in concert with the IOM definition of quality,1 which includes
patient-centeredness as a goal, the committee recommends the NOHI pur-
sue a focus on patient-centered (and community-centered) care and there-
fore seek ways to ensure that the patient’s and consumer’s perspectives
(including those of private-sector and other public-sector stakeholders) is
recognized and appreciated in future oral health planning.
Focusing on Prevention
Among the most important contributions that HHS can make to im-
prove oral health is to promote the use of regimens and services that have
been shown to promote oral health, prevent oral diseases, and help manage
these diseases. Too often, oral health care focuses more intently on treating
disease once it has already become manifest. A focus on prevention may
help to reduce the overall need for treatment, reduce costs, and improve the
capacity of the system to care for those in need.
HHS plays a key role in promoting the adoption of evidence-based pre-
ventive oral health services, including those provided at the national, state,
community, and individual levels. For example, as discussed in Chapter 4,
the U.S. Preventive Services Task Force assesses the evidence about clinical
preventive services while the Task Force on Community Preventive Services
does the same for community-based preventive services. In addition to its
role in assessing preventive services, HHS and the federal government as a
whole directly provide (or oversee the provision of) a significant amount
of oral health care.
The committee concluded that (1) preventive services and counsel-
ing have a strong evidence base for promoting oral health and preventing
disease; and (2) HHS is a key provider of oral health care, especially for
vulnerable and underserved populations through the safety net. Therefore,
the committee recommends:
RECOMMENDATION 2: All relevant HHS agencies should promote
and monitor the use of evidence-based preventive services in oral health
1 In 2001, the IOM defined six dimensions of quality: safety, effectiveness, patient-
centeredness, timeliness, efficiency, and equity (IOM, 2001).
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212 ADVANCING ORAL HEALTH IN AMERICA
(both clinical and community based) and counseling across the life
span by
• Consulting with the U.S. Preventive Services Task Force and the
Task Force on Community Preventive Services to give priority to
evidentiary reviews of preventive services in oral health;
• Ensuring that HHS-administered health care systems (e.g., Fed-
erally Qualified Health Centers, Indian Health Service) provide
recommended preventive services and counseling to improve oral
health;
• Providing guidance and assistance to state and local health systems
to implement these same approaches; and
• Communicating with other federally administered health care sys-
tems to share best practices.
This recommendation is in alignment with the HHS Strategic Plan
for FY 2010–2015 that promotes “the incorporation of oral healthcare
services and oral disease prevention into primary healthcare delivery sites”
and “policies to integrate oral health into primary care, including preven-
tion and improved health literacy” (HHS, 2010c). Overall, the plan states
“Improved availability of oral health services, including disease prevention,
treatment, and health promotion and education, should be promoted for
poor and underserved populations as well as for the population at large.”
A first step for the U.S. Preventive Services Task Force and the Task
Force on Community Preventive Services would be to reexamine modali-
ties that have been looked at previously but had insufficient evidence (see
Chapter 4). The committee encourages the provision of preventive services
in HHS-administered health care systems by any and all health care pro-
fessionals who are competent to do so; for example, physicians, nurses,
and others could be involved either through direct provision of care (e.g.,
fluoride varnish) or through examination, risk assessment, and appropri-
ate referrals as needed. Assistance to state and local health systems could
include both financial assistance and technical assistance, through the shar-
ing of best practices. Consideration will also be needed for the adequacy
of and support needed for the public health infrastructure to support these
activities—both at the federal and the state level. HRSA’s regional offices
might be one option to provide technical assistance at the state and local
levels. The Centers for Disease Control and Prevention’s (CDC’s) grants to
states for supporting public health infrastructure also could help encourage
these activities.
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Improving Oral Health Literacy
Overall, evidence suggests that the general oral health literacy of both
individuals and all types of health care professionals is poor, especially
in understanding the causes and prevention of oral diseases and how to
communicate about these issues. For example, despite decades of evidence
regarding the infectious nature of dental caries and the value of fluoride in
preventing dental caries, both professional and patient knowledge regarding
these issues remains lacking. In addition, poor oral health literacy contrib-
utes to poor access because individuals may not understand the importance
of oral health care or their options for accessing such care.
The committee concluded that the oral health literacy of individuals,
communities, and all types of health care providers remains low. This
includes knowing how to prevent and manage oral diseases, the impact
of poor oral health, how to navigate the oral health care system, and best
techniques in patient–provider communication. Therefore, the committee
recommends:
RECOMMENDATION 3: All relevant HHS agencies should undertake
oral health literacy and education efforts aimed at individuals, com-
munities, and health care professionals. These efforts should include,
but not be limited to,
• Community-wide public education on the causes and implications
of oral diseases and the effectiveness of preventive interventions;
o Focus areas should include
■ The infectious nature of dental caries,
■ The effectiveness of fluorides and sealants,
■ The role of diet and nutrition in oral health, and
■ How oral diseases affect other health conditions.
• Community-wide guidance on how to access oral health care; and
o Focus areas should include using and promoting websites such
as the National Oral Health Clearinghouse and www.health
care.gov.
• Professional education on best practices in patient–provider com-
munication skills that result in improved oral health behaviors.
o Focus areas should include how to communicate to an increas-
ingly diverse population about prevention of oral cancers, dental
caries, and periodontal disease.
As described in relation to the previous recommendation, this current
recommendation aligns with the HHS Strategic Plan for FY 2010–2015
that calls for improvements in oral health literacy and oral health promo-
tion and education (HHS, 2010c). In her presentation to this commit-
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214 ADVANCING ORAL HEALTH IN AMERICA
tee, Dr. Marcia Brand, deputy administrator of the Health Resources and
Services Administration (HRSA), noted that as part of the statement of
task, HHS was interested in learning more about how to increase public
awareness and communicate specific messages of the relationship between
good oral health and good overall health (Brand, 2010). She also noted
that HRSA was interested in the oral health literacy of all types of health
care professionals, including what types of messages could be sent to them
regarding prevention of oral diseases (and how to communicate these mes-
sages). The committee did not find enough evidence specifically in the oral
health literacy and behavioral change literature to recommend exact strate-
gies for delivering needed messages; therefore, it has given examples within
the recommendation of the areas that have the most evidence supporting
the need for outreach in these areas. (Research in oral health behavioral
change will be discussed later in these recommendations.) The committee
intends the highlighting of these areas to provide direction for HHS. In ad-
dition, the CDC might consider targeting these areas if the CDC oral health
campaign related to prevention authorized in the Affordable Care Act (see
Chapter 4) is eventually funded. The committee fully supports the funding
of this national campaign to promote awareness of oral health promotion
and disease prevention. In addition, this type of campaign represents an-
other opportunity where input from other public and private stakeholders
would be valuable, especially in learning about successes and failures of
other individual campaigns. Finally, the committee recognizes that any
literacy and education efforts should be carried out in accordance with
standards for culturally and linguistically appropriate services.
Enhancing the Delivery of Oral Health Care
To meet the oral health care needs of the U.S. population, several
workforce changes are needed. Dental professionals need more training in
community-based settings in order to learn more about caring for under-
served and vulnerable populations. Nondental health care professionals
(e.g., nurses, pharmacists, physician assistants, physicians) are often not
prepared to provide basic oral health care. This may include being able
to recognize disease, teaching patients about self-care, or providing basic
preventive services. In addition, both dental and nondental health care
professionals need better training in collaborative efforts, including the
appropriate use of referrals in both directions, and more research will be
needed to understand best approaches. For example, examinations of team-
based care may need to consider how health information technology might
be used, such as through the integration of medical and dental electronic
records. The emergence of new types of dental professionals and the use
of existing professionals in expanded roles, as discussed in previous chap-
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ters, has been contentious for decades. Other health care professions have
expanded roles for existing professionals in high-risk situations, and these
efforts have also been accompanied by political tension between profes-
sions. While the evidence in this country on the quality of oral health care
provided by health professionals who are not dentists is early and limited,
without further research and evaluation, including a comparison of the
quality of that care as compared to the care of dentists, better workforce
models cannot be developed. Finally, particular attention is needed for
underrepresented minority groups who often suffer from disparities in oral
health. Health care professionals who are themselves from underrepre-
sented minority groups often care for a larger proportion of patients from
these populations. However, the racial and ethnic makeup of the dental
professions has not changed markedly over time, and while programs such
as bridge and pipeline programs have had some successes, newer models
and methods of attracting a diverse student body need to be explored.
The committee concluded that (1) nondental health care profession-
als are well situated to play an increased role in oral health care, but they
require improved education and training; (2) interprofessional, team-based
care has the potential to improve care-coordination, patient outcomes, and
produce cost-savings, yet dental and nondental health care professionals
are largely not trained to work in this manner; (3) new dental professionals
and existing professionals with expanded duties may have a role to play in
expanding access to care; and (4) efforts to broaden the diversity of the oral
health care workforce have not produced marked changes.
While the regulation of health care professions occurs at the state level,
HHS has a role to play in both the education and training of the health
care workforce (as noted in Chapter 4) as well as the demonstration and
testing of new innovative workforce models for specific needs (as noted in
Chapter 3 and through elements of the Affordable Care Act and the HHS
Strategic plan, both described in Chapter 4). These issues all require in-
novative research and demonstration efforts in order to more fully develop
the evidence base on their value and best use. Therefore, the committee
recommends:
RECOMMENDATION 4: HHS should invest in workforce innova-
tions to improve oral health that focus on
• Core competency development, education, and training, to allow
for the use of all health care professionals in oral health care;
• Interprofessional, team-based approaches to the prevention and
treatment of oral diseases;
• Best use of new and existing oral health care professionals; and
• Increasing the diversity and improving the cultural competence of
the workforce providing oral health care.
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216 ADVANCING ORAL HEALTH IN AMERICA
This recommendation aligns with the HHS Strategic Plan for FY 2010–
2015. One of the five identified goals of the plan is “Strengthen the nation’s
health and human service infrastructure and workforce” through objectives
that address improving cultural competence and expanding care teams
(including the use of new types of professionals). In fact, the plan has an
explicit strategy for oral health: “Expand the primary oral health care team
and promote models that incorporate new providers, expanded scope of
existing providers, and utilization of medical providers to provide evidence-
based oral health preventive services, where appropriate” (HHS, 2010c).
In addition to the training and composition of the oral health work-
force, more needs to be done to consider alternatives to how oral health
care can be delivered and financed to improve availability and scope of
oral health coverage and care. Chapter 3 gives an overview to the financing
of oral health care. Dental coverage is strongly associated with receiving
oral health care, yet many Americans, especially older adults, do not have
this coverage. The separation of dental coverage from overall health care
coverage reinforces the separation of oral health from overall health. The
committee concluded that oral health care is so integral to the overall health
of individuals and the population that financing of these services would ide-
ally be part of every health plan. However, the committee also recognizes
the current political and economic infeasibility of seeking to have all oral
health services covered under health care plans.
The committee found that not enough research has been done to deter-
mine if alternative payment mechanisms might be more efficient to finance
oral health care and pay for delivery of the most effective services in the
most efficient manner, or to determine if the delivery of preventive services
would result in long-term cost savings (which would have implications for
the scope of coverage). Some consideration might be needed for how the
current compensation system drives the delivery of oral health care. For
example, like in general health care, fee-for-service payment structures of-
ten reinforce the delivery of treatment services rather than preventive care.
Like in general health care financing, exploration is likely needed for how
alternative payment structures such as the bundling of payments and pay
for performance might affect care delivery.
Also like in the general health care system, incentives may be needed to
encourage oral health care providers to work in underserved areas or with
underserved populations, such as increased payments for Medicaid provid-
ers or reimbursement for services performed by nondental health care pro-
fessionals. Chapter 3 describes the delivery of oral health care services, yet
also recognizes that distinct segments of the American public are not well
served by the current system and that alternative solutions need to be ex-
plored (as discussed in the previous recommendation). As more members of
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A NEW ORAL HEALTH INITIATIVE
the overall health care workforce become competent and licensed to deliver
care, research will be needed for how they will work and be reimbursed.
In January 2010, the Advisory Committee on Training in Primary Care
Medicine and Dentistry said, “CMS needs to work with primary care lead-
ership organizations to develop strategies to redefine how to deliver and
reimburse primary care (HHS, 2010b).” It added,
CMS should pilot and evaluate reimbursement strategies that compensate
for nontraditional approaches to care such as group visits, telephone and
electronic communication, care management, and incorporation of non-
traditional provider types (such as patient educators, patient navigators,
and community health workers).
They suggested that such approaches could both improve outcomes
and contain costs.
The committee concluded that (1) distinct segments of the U.S. popu-
lation have challenges with accessing care in typical settings of care; (2)
lack of dental coverage contributes to access problems; (3) newer financing
mechanisms might help contain costs and improve health outcomes; and (4)
new delivery models need to be explored to improve efficiency. Therefore,
the committee recommends:
RECOMMENDATION 5: CMS should explore new delivery and pay-
ment models for Medicare, Medicaid, and CHIP to improve access,
quality, and coverage of oral health care across the life span.
The committee notes that one option for how CMS could explore some
of these models is through the Center for Medicare and Medicaid Innova-
tion (the “Innovation Center”), which was established within HHS under
a provision of the Affordable Care Act of 2010. The Innovation Center is
focused on achieving improvements in three areas:
1. Better care for people (improving patient care across inpatient and
outpatient settings, and developing ways to make care safer, more
patient-centered, more efficient, more effective, more timely, and more
equitable);
2. Care coordination (developing new models for transprofessional col-
laboration); and
3. Improved community care models (initiatives designed to improve the
health of communities (e.g., obesity and heart disease) (Berwick, 2010).
The Innovation Center will help to identify, support, and evaluate mod-
els of care that improve the quality of care while also lowering costs. This
includes demonstration projects on the effectiveness of team care and the
impact of more coordinated payments (Carey, 2010; CMS, 2010b).
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As with the previous recommendations, this recommendation aligns
with the HHS Strategic Plan for 2010–2015 for its focus on improving
how care is delivered. In addition, the plan identifies an overarching goal to
“transform health care,” including specific objectives to create new models
for health delivery and payment that promote effective care and reduce
costs (HHS, 2010c).
Expanding Research
Throughout the evidence-gathering process for this report, the commit-
tee noted a significant lack of robust evidence related to many different as-
pects of oral health care. While Chapter 2 highlighted significant oral health
disparities between different populations, not enough is known about the
best ways to decrease these disparities. Similarly, Chapter 2 describes the
basics of health literacy practices and principles, including its relationship
to disease management and behavioral change. The chapter highlights that
although methods of preventing oral disease are well established, knowl-
edge of these methods is still limited, both on the part of the public and
even many professionals. In addition, not enough evidence yet exists to
determine the best methods for changing behaviors in oral health specifi-
cally. Chapter 3 notes that very little evidence exists for the quality of oral
health services. Very few measures of quality exist for oral health, leading
to little evidence not only about the quality of the services themselves but
also about their ultimate relationship to long-term improvements in oral
health. Quality assessment efforts in oral health lag far behind analagous
efforts in medicine. Finally, in Chapter 4 the committee describes the role
of many other federal agencies in the oral health care of a significant num-
ber of Americans. The committee recognizes that these other agencies all
have data collection systems and that consolidation of the data collected by
these multiple sources would be useful in performing secondary research in
oral health by many types of researchers. However, much effort would be
needed to make all of these data usable.
Based on the findings in all of these chapters, the committee concluded
that a more robust evidence base in oral health is needed overall. The com-
mittee concluded that efforts are needed most toward (1) generating new
evidence on best practices; (2) improving the usefulness of existing data;
and (3) evaluating the quality of oral health care (including outcomes).
Therefore, the committee recommends:
RECOMMENDATION 6: HHS should place a high priority on efforts
to improve open, actionable, and timely information to advance science
and improve oral health through research by
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A NEW ORAL HEALTH INITIATIVE
Leveraging resources for research to promote a more robust evi-
•
dence base specific to oral health care, including, but not limited
to,
o oral health disparities, and
o best practices in oral health care and oral health behavior
change;
Working across HHS agencies— in collaboration with other federal
•
departments (e.g., Department of Defense, Veterans Administra-
tion) involved in the collection of oral health data—to integrate,
standardize, and promote public availability of relevant databases;
and
Promoting the creation and implementation of new, useful, and
•
appropriate measures of quality oral health care practices, cost and
efficiency, and oral health outcomes.
In terms of “leveraging resources,” the committee supports the direc-
tion of new funding toward research, but in recognizing that this is a time
of limited resources, it emphasizes that HHS should prioritize oral health
research when deciding upon distribution of existing resources. While the
committee fully supports fundamental research that underpins oral health,
again, in a time of limited (or diminishing) resources, the committee asserts
that research in disparities, best practices, and behavioral change are areas
that are especially lacking in evidence and could have a great impact on
long-term goals. Research on oral health disparities is especially needed to
understand best approaches to reducing those disparities. The research into
best practices in oral health should be interpreted broadly because many
areas of research are still needed related to individual procedures, oral
health literacy, interprofesssional approaches, and many other areas, all of
which contribute to oral health overall. In addition, part of this research
will require consideration of how to transfer oral health research results
into use by appropriate user groups.
As previously noted, the committee sees that in addition to the need for
new primary research, many databases already exist in multiple places, but
they are not currently structured in a manner that allows for full integration
of these data. Examples of data sets that include oral health information
include the Medical Expenditure Panel Survey, the National Health and
Nutrition Examination Survey, the Pregnancy Risk Assessment Monitor-
ing System, and the National Health Interview Survey, among many oth-
ers. Nearly all of the data sets are supported, at least in part, by different
branches of the federal government. Some of these, however, do not have
recent data.
The primary purpose here would be for secondary research on the vast
amounts of existing data that are not being used efficiently. In addition to
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the publicly available data sets, there are many other data sets that exist
and contain useful data. While the committee recognizes that some data
may not be able to be shared (e.g., sensitive data such as in cases of mili-
tary databases), these data, whenever possible, should be made available
to all researchers. For example, HHS’ Community Health Data Initiative
and CMS’s and the VA’s Blue Button Initiative are current efforts to share
standardized data with the public regarding health and health care in order
to foster better public understanding of health care performance and per-
sonal health as well as to promote innovative use of the data for the public’s
benefit (CMS, 2010a; HHS, 2011a).
Finally, many challenges lie ahead for the development of more robust
measures in oral health, including the lack of a universally used diagnostic
coding system as well as challenges in collecting data from single practice
settings. While HHS can require the use of diagnostic codes in their own
systems, they cannot mandate their use in the private sector. Overall, the
federal government has a great opportunity to assist in this process, both
because of the wealth of existing data as well as because of its role in op-
erating large systems of care.
Measuring Progress
Finally, the committee concluded that an effective NOHI needs an on-
going process for maintaining accountability, and for measuring progress
toward achieving specific goals of improved oral health. Therefore, the
committee recommends:
RECOMMENDATION 7: To evaluate the NOHI the leader(s) of the
NOHI should convene an annual public meeting of the agency heads
to report on the progress of the NOHI, including
• Progress of each agency in reaching goals;
• New innovations and data;
• Dissemination of best practices and data into the community; and
• Improvement in health outcomes of populations served by HHS
programs, especially as they relate to Healthy People 2020 goals
and specific objectives. HHS should provide a forum for public
response and comment and make the final proceedings of each
meeting available to the public.
The committee makes this recommendation with the intention that
progress made on the NOHI is shared transparently with any and all
interested parties. This is an opportunity not only to measure progress in
implementing new programs and policies but also to share best practices
in the prevention and treatment of oral diseases, to share new knowledge
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(based on new research and demonstration projects), develop consistent
messages about oral health, and to monitor oral health outcomes related
to the efforts of HHS. Overall, the committee envisions that this meeting
be an opportunity to report on both short-term and intermediate goals
(as set by the individual agencies, as discussed in Recommendation 1) and
progress on Healthy People 2020 goals and objectives (the overall mission
of the NOHI). In addition, HHS needs to develop a mechanism to get
public feedback on the programs they are responsible for, ensuring that
consumers have a meaningful voice. The committee could not recommend
the exact interval of this meeting, recognizing both the time needed for the
start-up of new projects as well as the time needed to collect and evaluate
new data. The committee also does not intend for this recommendation
to preclude additional meetings that HHS might hold internally without
a public presence.
LOOKING TO THE FUTURE
In her presentation to this committee, Dr. Mary Wakefield, Admin-
istrator of HRSA, responded to questions from this committee regarding
the types of recommendations that might be most valuable for HHS. She
recognized that a balance of specificity and generality would be needed but
that the recommendations should be “actionable”—that is, recommenda-
tions that could be acted upon immediately but might have several methods
of implementation and thereby give flexibility. This committee asserts that
the framework and details of the previously outlined recommendations
does just this. The committee recognizes that many of the recommendations
made are not necessarily “new.” However, as the title of this report sug-
gests, the challenges and strategies illuminated by Oral Health in America
represent and remain the areas that have the strongest evidence for effecting
the needed changes.
As this committee looks to the future of HHS’ involvement in oral
health, questions arise regarding both the long-term viability of maintaining
oral health as a priority issue and the likelihood of the recommendations
of this report coming to fruition. In this vein, the committee has identified
three key areas that are needed for future success: strong leadership, sus-
tained interest, and the involvement of multiple stakeholders.
The Importance of Leadership
The foundation of the OHI 2010 provides many indications that lead-
ership for oral health is currently strong. The OHI 2010 is broader than
many previous efforts in that it involves many more HHS agencies and pro-
grams at multiple levels, which may result in more buy-in departmentally.
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222 ADVANCING ORAL HEALTH IN AMERICA
As the NOHI further calls for each agency to develop individual annual
plans and short-term goals, it involves individuals at the staff level, who
often drive programmatic activity, a structure that veterans of previous ini-
tiatives have said can be helpful. However, this also presents the challenge
of organizing and directing a multitude of agencies within HHS that are
highly independent and autonomous and may not always act in concert.
In her presentation to this committee, Dr. Wakefield noted that they were
working on signing a memorandum of agreement among CDC, CMS, and
HRSA to facilitate cross-agency work (Wakefield, 2010). The new NOHI
represents an additional challenge in that this committee calls for the in-
creased involvement of and collaboration with leaders from the private
sector and other segments of the public sector. These leaders are needed
partners to help improve cross-sector communication and coordination in
order to achieve significant improvements in oral health.
It appears that the current leadership at HHS is capable of meeting
these challenges. The OHI 2010 is rooted in strong, high-level interest in
that the Assistant Secretary for Health and the Administrator for CMS
co-lead the effort. In another example, in her presentation to this commit-
tee, Dr. Brand noted that HRSA had recently created an Office of Special
Health Affairs within its Office of Strategic Priorities that would focus on
two cross-cutting areas: oral health and behavioral health (Brand, 2010).
However, while leadership to promote oral health within HHS itself
appears strong, some have criticized the erosion of oral health expertise
and leadership within HHS. During the public workshop of the committee’s
second meeting, a discussion ensued about whether a formal dental leader-
ship position should be created in every agency. It was noted that creating
a multitude of new positions might not necessarily be matched with enough
individuals interested in entering government service, that positions for all
types of health care professionals were being eliminated in public agencies
to some degree, and that previous successes relied more on the interest from
the workers on the ground level. However, the committee does support the
need for individuals within HHS from all sectors of health care who are
well versed in oral health issues (both dental and nondental professionals)
and have an interest in promoting oral health.
Sustaining Interest
Regardless of how an initiative is structured, much of its long-term
viability depends on the interests and efforts of the individuals leading the
agencies and HHS, which can change in unpredictable ways over time. For
example, a key factor may be whether it can survive a change in presiden-
tial administrations, particularly one involving a change in parties. In her
presentation to this committee, Dr. Wakefield noted that while there hasn’t
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A NEW ORAL HEALTH INITIATIVE
been a formal focus on oral health across HHS, they saw the OHI 2010 as
an opportunity to leverage assets and interests to improve the recognition
of the importance of oral health to individuals and populations (Wakefield,
2010). Tragically, sustained interest is seen and promulgated in the case of
Deamonte Driver. Driver’s death in 2007 remains a high-profile example of
the worst-case scenario for poor oral health. To date, Driver’s story brings
an awareness to these issues that facts or figures cannot achieve. Long-term
viability depends on HHS itself making and keeping oral health a priority
issue.
In spite of evidence for the likelihood of sustained interest, several
warning signs have arisen recently that could contribute to a loss of mo-
mentum. First, in a February 2011 letter from the Secretary of HHS to state
governors regarding state budget concerns, she highlighted areas where
states could save money, including modifying benefits. The letter noted
that “while some benefits, such as hospital and physician services, are
required to be provided by State Medicaid programs, many services, such
as prescription drugs, dental services, and speech therapy, are optional”
(HHS, 2011b). The committee does recognize that in times of economic
challenges, such as we have now, many important health and health care
issues are competing for a limited pool of dollars. However, the burden of
oral disease, including both the economic and the social impact, needs to
be recognized as one of the grand challenges in the health of our nation.
Additionally, in early 2011, the CDC released the report CDC Health Dis-
parities and Inequalities in the United States—2011 in which oral disease
was not addressed at any level. The committee urges CDC to include oral
health in subsequent reports.
More significantly, in early 2011, the committee learned of the pro-
posed downgrading of the CDC’s Division of Oral Health (within the Na-
tional Center for Chronic Disease Prevention and Health Promotion) into a
branch of the Division of Adult and Community Health (ADA, 2011). Such
a change raises two serious concerns. First is that the Division of Adolescent
and School Health does not list oral health among the “important topics
that affect the health and well-being of children and adolescents” (CDC,
2011) despite the surgeon general’s finding that dental caries was the “the
single most common chronic childhood disease” (HHS, 2000). Therefore,
placement of oral health into the Division of Adult and Community Health
is likely to impede CDC’s ability to give direct attention to the oral health
needs of the U.S. population across the life span. The second concern is
that such a decision implies that CDC is placing a low priority on oral
health. This may be true of other HHS agencies as well. For example, the
committee noted that the Administration on Aging does not have any spe-
cific initiatives related to the oral health of older adults. The success of the
NOHI requires the active involvement of every agency within HHS. Similar
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224 ADVANCING ORAL HEALTH IN AMERICA
to the need for consistent messages to patients about the importance of oral
health, HHS needs consistent messaging within its own organization that
oral health is a priority.
Engaging Stakeholders
Finally, an important ingredient for the success of the NOHI is public-
private partnerships and grassroots involvement. As stated in Chapter 1, an
HHS initiative cannot on its own change the entire oral health care system.
While the committee agrees that HHS should look for ways to be a leader
for the rest of the country, they also need to be mindful of opportunities
to partner with and learn from other stakeholders. For example, the com-
mittee recognizes the efforts occurring in the private sector that should
not be supplanted or ignored. Throughout the recommendations for the
NOHI, there are examples and opportunities for HHS to work with other
stakeholders to combine efforts, share best practices, and pool resources.
Collective efforts in the different sectors are also key to the successful imple-
mentation of systems and services at the community level. There is also an
explicit effort both in the administrative structure of the NOHI and in the
reporting process to engage consumers and their communities so that ef-
forts remain patient and community focused, and that HHS remains openly
accountable to the people they serve.
The committee recognizes that bringing disparate sectors together to
effect significant change is a daunting task, but it is one well suited to the
mission and responsibilities of HHS. Every effort needs to be made by HHS
to collaborate with and learn from the private sector; other public sector
entities at the local, state, and national levels; and patients themselves to-
ward achieving the goal of improving the oral health care and, ultimately,
the oral health of the entire U.S. population. There are many reasons that
HHS can and should be a leader in improving oral health and oral health
care. However, most important is the burden that oral diseases are placing
on the health and well-being of the American people.
REFERENCES
ADA (American Dental Assocation). 2011. CDC decision to downgrade Division of Oral
Health a bad move, ADA protests. http://www.ada.org/advocacy.aspx#top (accessed
February 24, 2011).
Berwick, D. 2010. Introducing the CMS Center for Medicare & Medicaid Innovation—and
innovations.cms.gov. http://www.healthcare.gov/news/blog/InnovationCenter.html (ac -
cessed December 29, 2010).
Brand, M. 2010. Oral testimony of Dr. Marcia Brand, Deputy Administrator of the Health
Resources and Services Administration. Presentation at meeting of the Committee on an
Oral Health Initiative, Washington, DC. March 31, 2010.
OCR for page 225
225
A NEW ORAL HEALTH INITIATIVE
Carey, M. A. 2010. New Medicare/Medicaid projects aimed at cheaper, better care. http://
www.kaiserhealthnews.org/Stories/2010/November/17/cms-innovation-center-berwick.
aspx (accessed January 9, 2011).
CDC (Centers for Disease Control and Prevention). 2011. Healthy youth: Health topics.
http://www.cdc.gov/healthyyouth/healthtopics/index.htm (accessed February 28, 2011).
CMS (Centers for Medicare and Medicaid Services). 2010a. Blue Button Initiative. https://
www.cms.gov/NonIdentifiableDataFiles/12_BlueButtonInitiative.asp (accessed January
10, 2011).
CMS. 2010b. CMS introduces new Center for Medicare and Medicaid Innovation, initiatives
to better coordinate health care. http://innovations.cms.gov/innovations/pressreleases/
pr110910.shtml (accessed December 29, 2010).
Crall, J. J. 2009. Oral health policy development since the surgeon general’s report on oral
health. Academic Pediatrics 9(6):476-482.
HHS (Department of Health and Human Services). 2000. Oral health in America: A report
of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services.
HHS. 2010a. About HHS. http://www.hhs.gov/about/ (accessed December 29, 2010).
HHS. 2010b. Advisory committee on training in primary care medicine and dentistry: The
redesign of primary care with implications for training. Rockville, MD: U.S. Department
of Health and Human Services.
HHS. 2010c. Strategic plan and priorities. http://www.hhs.gov/secretary/about/priorities/
priorities.html (accessed December 29, 2010).
HHS. 2011a. Community health data initiative. http://www.hhs.gov/open/plan/open
governmentplan/initiatives/initiative.html (accessed January 10, 2011).
HHS. 2011b. Sebelius outlines state flexibility and federal support available for Medicaid.
http://www.hhs.gov/news/press/2011pres/01/20110203c.html (accessed February 24,
2011).
IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the
21st century. Washington, DC: National Academy Press.
Mertz, E., and W. E. Mouradian. 2009. Addressing children’s oral health in the new millen-
nium: Trends in the dental workforce. Academic Pediatrics 9(6):433-439.
Mouradian, W. E., R. L. Slayton, W. R. Maas, D. V. Kleinman, H. C. Slavkin, D. DePaola, C.
Evans, and J. Wilentz. (2009) Progress in children’s oral health since the surgeon general’s
report on oral health. Academic Pediatrics. 9(6):374-379.
Slayton, R. L., and H. C. Slavkin. 2009. Commentary: Scientific investments continue to fuel
improvements in oral health (May 2000–2009). Academic Pediatrics 9(6):383-385.
Wakefield, M. 2010. Oral testimony of Dr. Mary Wakefield, Administrator of the Health
Resources and Services Administration. Presentation at meeting of the Committee on an
Oral Health Initiative, Washington, DC. June 28, 2010.
OCR for page 226
