Oral Health: An Evidence and Data-Driven Approach to Achieve Better Health, Equity, and Fiscal Responsibility
Natalia I. Chalmers DDS, MHSc, PhD
Diplomate, American Board of Pediatric Dentistry
Chief Dental Officer
Office of the Administrator
Centers For Medicare & Medicaid Services
The State of Oral Health:
Increasing Access & Reducing Disparities
The National Institute for Health Care Management Foundation
November 9, 2021
CMS Vision Statement
CMS serves the public as a trusted partner and steward, dedicated to advancing health equity, expanding coverage, and improving health outcomes
2
Advance Health Equity by addressing
the health disparities that underline
our health system.
Build on the Affordable Care Act and expand access
to quality affordable
health coverage and
care.
Engage our partners and the communities we
serve
throughout the policymaking
and
implementation process.
Drive innovation to
tackle our health system
challenges and promote value-based,
person centered care
Protect our programs’
sustainability for future generations by
serving as a responsible steward of public funds.
Foster a positive and
inclusive workplace and workforce, and
promote excellence in all aspects of
operations.CMS
“You’re Not Healthy Without Good Oral Health.”
– Surgeon General C. Everett Koop
Oral Health is About
Equity, Fiscal Responsibility and Inflammation
Equity Fiscal
Responsibility
Inflammation
(Clinical Outcomes)
10.4 11.1
9.5
6.7
14.8 15.1
17.2
9.9
6.0
Total Male Female White, non-
Hispanicc Black, non-
Hispanic Mexican
American <100%FPL 100%–199%
FPL
≥200% FPL
Prevalence of Untreated Tooth Decay In
Primary Teeth Among Children Aged 2–5 Years
Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2016 5
Percent
Racial Disparities Income Disparities
Prevalence of Periodontitis in Adults
25.3
37.8
48.7
66
60.4
50
39
59.7 59.8
56.6
46.2
30.7
30–34
35–49
50–64 65±
Hispanics
Non-Hispanic Asian
Non-Hispanic White
Non-Hispanic Black
< 100% FPL 100
–199% FPL 200
–499% FPL ≥400% FPL
Source: Eke et al. Prevalence of Periodontitis in Adults in the United States: NHANES 2009 to 2012. J Periodontol. 2015 6
Proportion
Increases with age Racial Disparities Income Disparities
Prevalence of Complete Tooth Loss
(Edentulism) among Adults Aged 65 and Over
Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012. 7
18.6
13
25.8
17.5 19.4
16.9
29.2
14.9
24.2
Total 65–74 75 and over Men Women Non-Hispanic
white
Non-Hispanic black
Hispanic Non-Hispanic Asian
Percent
Increases with age Racial Disparities
Dental Visit in the Past Year By Poverty
Source: Yarbrough and Vujicic Oral health trends for older Americans JADA 2019 8
Income Disparities
Total inflammation surfaces are approximately the same.
Nonhealing Ulcer over the Ulnar Aspect of the Left Forearm
Chronic periodontal disease
Poor Oral Health, Infection and Inflammation
Fitzgerald Arch Dis Child 2005 The New England Journal of Medicine, 2002
Periodontal Disease and Associated Inflammatory Comorbidities
Source: Hajishengallis and Chavakis Nat Rev Immunol 2021 10
Periodontitis Inflammatory Comorbidities
• Cardiovascular disease
• Type 2 diabetes mellitus
• Rheumatoid arthritis
• Inflammatory bowel disease
• Alzheimer disease
• Nonalcoholic fatty liver disease
• Cancers Dissemination
• Bacteremia, hematogenous
• Oro-pharyngeal dissemination
• Oro-digestive dissemination
Poor Oral Health Has Impacts Beyond Healthcare
Poor oral health is an obstacle to employment.
Poor oral health impacts children's school attendance and performance.
Poor oral health is linked to substance use disorders.
Poor oral health is linked to all-cause mortality.
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Inpatient Admission
Ambulatory Surgery
Emergency Department
Urgent Clinic
Where Patients Present with Oral Health Needs
Health Information Technology Divide Diagnostic Coding
Integration and Coordination of Care
Percentage of Medicaid Eligibles Ages 1 to 20 Who Received Preventive Dental Services
Source: medicaid.gov Children's Health Care Quality Measures 13
30 - 43 44 - 48 49 - 51 52 - 70
2019
Annual Dental or Medical Visits
14
49.7%
4.1%
27.9%
54.6%
62.8%
58.8%
49.2%
30.2%
51.6%
91.7%
79.4%
62.5%
46.1% 47.4%
38.7%
18.1%
Total < 1 1-2 3-5 6-9 10-14 15-18 19-20
Any Dental Service Medical Visit
Source: 2018 Annual Early and Periodic Screening, Diagnostic and Treatment (EPSDT), National
Age of Beneficiaries
Proportion of beneficiaries with visit in 2018
Oral Health Services by a Non-Dentist Provider
Source: 2018, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) 1- to 2-Year-Old; Hatched overlay over states in Medicaid and 15 CHIP Learning Collaborative “Advancing Prevention and Reducing Childhood Caries”
National Health Expenditure
Source: National Health Expenditure, Centers for Medicare and Medicaid Services
Dental is 4% of all Health Expenditures, $124 Billion
2016 Health Care Spending
Source: Dieleman et al. JAMA 2020 US Health Care Spending by Payer and Health Condition, 1996-2016
Health Care Service Expenditures per Capita for Selected Service Types Among Medicare Beneficiaries Living Only in the
Community, in Dollars, 2018
Source: Centers for Medicare & Medicaid Services, Medicare Current Beneficiary Survey, Survey File, 2018 and Cost Supplement File, 2018
TotalOut-of-Pocket 19%
14%
77%
6%
2%
Physician/Supplier Services Prescription Drugs Dental Services Outpatient Hospital Services
Inpatient Hospital Services
Out-of-Pocket as a Proportion of Total Expenditures
Dental services have the highest out-of-pocket rate.
EMERGENCY DEPARTMENT VISITS FOR DENTAL CONDITIONS
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Fiscal Responsibility
Equity Readmissions Mortality Opioids Antibiotics
Emergency Department Visits for Dental Conditions
Source: ADA Health Policy Institute 20
Percentage of Emergency Department Visits by Adults at which Opioids were Prescribed
Source: National Center for Health Statistics Report 135, 2020 21
Medicaid Adult Beneficiaries Emergency Department Visits for Non-Traumatic Dental Conditions
Center for
Medicaid and CHIP
Services
Oral Health: Challenges and Opportunities
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Increased Enrollment System
Capacity PPE Forgone
Care
School-based Programs Pandemic
Telehealth Vaccines and
Vaccination
