DrBicuspid.com is pleased to present the next installment of Leaders in Dentistry, a series of interviews with researchers, practitioners, and opinion leaders who are influencing the practice of dentistry.
We spoke with Lynn Mouden, DDS, MPH, chief dental officer at the U.S. Centers for Medicare and Medicaid Services.
Dr. Mouden earned his Doctor of Dental Surgery degree from the University of Missouri-Kansas City in 1975. He worked in private practice for 16 years in the small town of Weston, MO, before moving into dental public health. He earned his Master of Public Health degree from the University of North Carolina and worked as an associate chief for the Bureau of Dental Health at the Missouri Department of Health and Senior Services before moving on to Arkansas, where for 12 years, he served as the director of the state Department of Health Office of Oral Health.
Dr. Mouden took over as chief dental officer at CMS in February. In our interview, he spoke about the challenges he faces at his new post, where he is charged with providing oral health expertise and support for Medicaid and the Children's Health Insurance Program (CHIP).
DrBicuspid.com: You have worked as a private practice dentist and in dental public health on the state level. Will these experiences help you in the task of getting Medicaid dental care to a national population?
Dr. Mouden: Let me try and keep it in perspective. When I was in private practice, I had about 5,000 patients. When I was dental director in Arkansas, I had about 2.9 million patients. And now I figure I've got about 30 million children on Medicaid. The good news is that I was a Medicaid dentist for many years. I have worked with patients and provided their care. I wish everybody could have that experience to see why oral health really is so important. There is nothing more heart-wrenching than having a child in the chair who has been in pain for so long that as soon as they are numb they go sound asleep because they've been up for so many nights with a toothache. That will bring you into the public health and the Medicaid realm right away.
Now that you have had a chance to get settled in your new job, what do you see as your main goals?
Obviously, public health gives me a chance to focus on the prevention aspects of what we can do in oral health. It's cheaper than treatment. And of course CMS has an oral health initiative that has two major goals: preventive dental services for children and increased dental sealants for Medicaid children. My goal here at the beginning is pretty simple: ensuring that every child that is eligible for Medicaid has access to appropriate, comprehensive dental care.
With an estimated two-thirds of Medicaid children currently not getting the care they need, how are you going to get there?
There are lots of things going on. We can concentrate on prevention, and with the new emphasis on that, it means there will be less disease to treat. That is going to be a major focus. Then we have all the issues of providers. I know that, especially in some parts of the country, reimbursement rates are not what they need to be. We also know that raising reimbursement rates is not the total answer. There are issues that need to be addressed. Relieving administrative burdens. We need to make it easier for dentists to participate in Medicaid so these children really can get access to the care they need.
What about the workforce itself? Millions of Americans are living in dental health provider shortage areas.
We've got several different ideas out there. The ADA has its community dental health coordinator. Then there's the idea of the dental health aide therapist and the advanced practice dental hygienist. All of these ideas have come about because everyone knows that we have to do something to increase access to care. Whether one of those is going to be the answer or some combination or whatever it is, we have the opportunity in this country to provide the best dental care in the world. We just have to make sure more people can get access to the care they need.
In 2011, near the end of your tenure as director for the Arkansas Department of Health Office of Oral Health, bills were passed in the state Legislature to expand preventive oral health services in Arkansas. One supported fluoridation efforts in the state; another allowed hygienists to provide care in public health settings without the direct supervision of dentists; a third enabled physicians and nurses to apply fluoride varnishes. Could you talk about the passage of those pieces of legislation?
In the Pew Center on the States report that came out a couple years ago ("The Cost of Delay"), Arkansas actually got an F. In retrospect, I have to say I was thrilled, because finally we got the attention of the Legislature. Sen. David Johnson (D-Little Rock) was really the champion because it was his personal goal that Arkansas wasn't going to be at the bottom of the list anymore. He actually sponsored all three of those bills.
When we first went to the governor with this oral health package, he was thrilled because we had the dental association, the hygiene association, the health department, and so many others really behind all three of these.
As you well understand, when we are talking about a fluoridation guarantee, there are those who were not necessarily supportive. We frankly had considerable opposition to that bill, but we did get it passed and Arkansas will go from about 65% fluoridation to more than 87%. We will have the dental hygienists working in what is called a collaborative practice, doing the things that they are trained to do without the patient having first been seen by the dentist. The third one you mentioned allows physicians and nurses to do fluoride varnish after they've had the appropriate training in caries risk assessment.
Of course people asked me about what was the secret of getting these done? Just keep at it for 12 years.
Under the Patient Protection and Affordable Care Act, it has been estimated that more than 5 million currently uninsured children will receive dental benefits through Medicaid, CHIP, and health insurance exchanges. If the U.S. Supreme Court allows the healthcare reform law to stand, will these children actually be able to find the care they need?
What we think of as insurance, whether it's through Medicaid, CHIP, or through exchanges or other private-pay mechanisms, is no guarantee of access. We must continue to rely on, and continue to build, a competent, diverse workforce participating in providing that care.
A number of states have cut oral health services for adults under Medicaid in response to the economic downturn. Is there a way to get more care to the poor adults who need it besides holding Mission of Mercy events at county fairgrounds and gymnasiums?
Because the coverage for children is required in Medicaid programs, what we prevent today doesn't have to be retreated when we are talking about adults. I have worked at Missions of Mercy. I have been in five of them. And I love the fact that so many people will come together to provide this care. But I always go back to the old saying that charity is not a system of care. Providing free care two days a year or such isn't really going to address the problem. Luckily, we have these prevention strategies that will help alleviate this burden of disease.
Do you foresee a day when we won't have nearly 50 million Americans living in dental healthcare provider shortage areas?
The good thing is that basically everybody in oral health and healthcare in general realizes that change is necessary. We all realize there are different ways to provide care. It may require using different members of the healthcare team. We can't drill, fill, and bill our way out of the oral health crisis, especially in underserved populations, so we have to prevent disease. And we have to keep reminding people that whether it's through an oral health literacy or general awareness campaign like the Ad Council is going to present this summer, oral health isn't just about teeth. What we are talking about is not only dental health but general health. We have to get everybody on board with all these steps so that every American can enjoy the benefits of oral health.