Gary and Mary West Senior Dental Center Comments for the 2020 U.S. Surgeon General’s Report on Oral Health

RE:   The 2020 Surgeon General’s Report on Oral Health: The Specials Needs of Older Americans and the Shortfall in Medicaid Coverage

January 25, 2019

Attn:     Ms. Michelle Pitt

To the Editors of the Updated Surgeon General’s Report on Oral Health:

As the CEO and Dental Director of the nonprofit Gary and Mary West Senior Dental Center (GMWSDC), I am writing to provide public comment on the upcoming Surgeon General’s Report on Oral Health, in particular, to address “Part Four: How Is Oral Health Promoted and Maintained and How Are Oral Diseases Prevented?” The GMWSDC provides affordable, high-quality oral healthcare with comprehensive education, clinical and wellness services for seniors in need, enabling them to live healthier and more productive lives.

The GMWSDC is located on the second floor of the bustling Serving Seniors’ Gary and Mary West Senior Wellness Center in downtown San Diego, a separate nonprofit community-based organization that provides meals and supportive services to more than 500 low-income seniors daily. We are one of the only dental clinics in the country embedded within a community-based organization for seniors. This non-traditional setting has broken down three critical barriers that impeded low-income seniors’ access to care: cost, transportation, and lack of providers accepting Denti-Cal (a California’s state Medicaid benefit). Additionally, our partnership with Serving Seniors and using shared electronic records has created a seamless system of whole-person coordinated care that includes a comprehensive geriatric assessment and an oral health education class prior to dental treatment.

In just over two years since opening, GMWSDC has treated more than 900 unique patients over the course of 8,700 visits. We have an astoundingly low 5 percent no-show rate for appointments, which can be attributed not only to the great demand for our services, but also to the successful implementation of the clinic within the wellness center, which is conveniently located near public transportation lines. As part of our goal to bring services to more vulnerable seniors, in March 2019, we will expand upon our model of integrated care by opening our first satellite location co-located within a forthcoming PACE (Program of All-Inclusive Care for the Elderly) center in north county San Diego. In fact, as you update Chapter 7L of your report — “Community and Other Approaches to Promote Oral Health and Prevent Oral Disease” — please consider recognizing our clinic as a successful example of innovation.

Our inventive, integrated community-based system of care for seniors is not without challenges, and the Surgeon General’s Report on Oral Health has an important opportunity to highlight the gaps in access to care and the unique needs of the senior population. Cost continues to be the most-cited barrier to dental care for seniors in the United States. According to the American Dental Association’s Health Policy Institute, the gap in dental care use between low-income and high-income seniors is widening, which highlights inequalities in access to benefits and dental services. The majority of seniors lack any form of dental insurance. For lower-income seniors, paying out of pocket is not an option. While Medicaid coverage provides some support and California does have an adult benefit in Denti-Cal, limitations in coverage and payment mean Medicaid eligibility does not imply access. Almost 85 percent of our patients are Medicaid beneficiaries. When we opened, many of our initial patients had lacked dental care for a period of years, creating an accumulation of more complex and sometimes costly dental disease—and requiring multiple visits over extended periods to restore their oral health function.

Many of our low-income senior patients have chronic medical, mental health, behavioral, or developmental conditions that have made access to dental care a further challenge. More time is required to appropriately manage these patients’ medical or mental health condition(s) to ensure they receive the care they need. These individuals often need more frequent dental visits to monitor their increased risk of oral disease due to aging and the effects of medication. Usually, there is no mechanism by which to receive proper payment for the additional care required by persons with special needs. Payment levels are established for average, typically healthier patients. Fortunately, California has begun to address this issue. In 2018, Denti-Cal began providing a payment for the additional time dentists use to treat persons with special needs. Encouraging this type of payment reform is extremely important in securing access for the most difficult-to-treat patients.

Overall, the GMWSDC is working towards a sustainable model, but with the high needs of our patients due to years of dental neglect from lack of access to care coupled with current funding opportunities through reimbursement and state/federal funds, we operate at a net loss. The GMWSDC relies on philanthropy to cover the cost of providing care. Change must occur so others can bring oral healthcare to seniors who need it and provide high-quality care in a sustainable way.

The GMWSDC is actively involved in raising awareness of the oral health needs of seniors and forming partnerships to address this growing problem. I strongly encourage authors of the Report to focus on a vision for the future, including evidence-based research and policy recommendations that will ensure that the rapidly-growing demographic of older adults receives the care they need. I urge the authors to make this a forward-thinking report that focuses on addressing challenges on the horizon. This includes strong and clear language supporting oral health as part of overall health; demanding equity in coverage, access, and education; prioritizing preventive services through workforce, payment and education reform; and modeling community-driven solutions. As the oral health climate varies by state, it is imperative that your information-gathering process for the Report include regional hearings or input sessions and not simply webinars via teleconference. Meeting with local providers and advocates is the best way to capture how the complexities within oral health affect individuals, families, and communities.

Thank you for your commitment to addressing oral health and your partnership in improving the lives of individuals and communities.

Karen Becerra, DDS, MPH
CEO/Dental Director
Gary and Mary West Senior Dental Center