On September 13, the Health Care Council of Chicago (HC3), in collaboration with the American Dental Association (ADA), hosted a virtual discussion featuring an overview of the national and state policy landscape, outlining some of the challenges and opportunities for more equitable access to these essential services, as well as insights from providers and community partners that are addressing these unmet needs in unique ways here in Chicago.
Jenny Poth, Vice President, Proprietary Investments, Ziegler
Panelists: Julie Frantsve Hawley, PhD, CAE, Executive Director, TAG Oral Care Center
Patricia Grant, PhD, Senior Vice President of Research, The Chicago Lighthouse
Michele Mitchell, MD, MBA, Executive Medical Director, Oak Street Health
Nicholas Reed, AuD, Assistant Professor, Epidemiology of Aging, Johns Hopkins Bloomberg School of Public Health
Marko Vujicic, PhD, Chief Economist & VP, Health Policy Institute, American Dental Association (ADA)
News Coverage LACK OF DENTAL, ORAL AND VISION CARE HARMS OLDER ADULTS,
EXPERTS SAY | Health News Illinois, September 15, 2022 | Link to Article Here
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Marko Vujicic, PhD (MV)
Marko’s work focuses on oral health. His team reviews data and research around vulnerable populations, which include older adults. He noted that hearing, vision, and dental are some of the health care issues with the biggest barriers, and this is especially true in dental. Sixteen percent of older adults said they could not afford essential dental care. Dental care is often the most out of reach of health care services because it is not included in core services. Unmet dental needs don’t just appear as consequences in the mouth – it affects well-being, ability to eat, and mental health. Furthermore, data shows that gum disease is correlated with higher health care costs. It is important to have these types of conversations to address these issues. Marko sees momentum building on these three areas that have traditionally been left out of “core health care.”
Michele Mitchell, MD, MBA (MM)
Although Oak Street Health does not provide these services, they are very invested in vision, dental, and hearing because their providers see how it impacts overall health, and how the cost and access challenges related to these services negatively impact their patients, especially Medicare patients. Oak Street does a lot to work with patients to better understand their insurance benefits related to vision, dental, and hearing.
Nicholas Reed, AuD (NR)
Nicholas (Nick) was trained as a clinician and found that it is very hard to present people with vision service options that are not covered by insurance and can cost thousands of dollars. In his work at Johns Hopkins, Nick brings a clinical perspective to his research on how hearing affects health care, and what we can do about it. Sometimes we have to reshape the system. Those with mild hearing loss have two times the risk of developing dementia. A Lancet study concluded that among modifiable risk factors, eliminating hearing loss alone could eliminate nine percent of dementia globally. From an economic perspective, adults with hearing loss spend more on health care and require the use of more health care, with $22,000 in excess medical expenditures. Nick and his colleagues have been working on policy issues to advance the Over-the-Counter Hearing Aid Act of 2017, as well as Medicaid expansion opportunities. Overall, the hearing care system is operating the same as it was when it was founded in the 1970s. We don’t live in that time anymore, don’t use analog devices, and are in the digital world, and there are changes that can be made to increase accessibility and affordability.
Patricia Grant, PhD (PG)
An estimated 99 percent of Medicare beneficiaries have vision issues. Medicare doesn’t cover vision services, and the associated financial burden contributes to vision loss-related ailments currently being experienced by older adults. There is a domino effect resulting from issues with vision and hearing on mental health and other components of an individual’s health. Preventive services are not covered, so it becomes an issue (for example, compromised hearing and vision can increase the risk of falls).
Julie Frantsve Hawley, PhD, CAE (JFH)
TAG is part of the Aspen Group supporting the business side of dental offices. TAG wanted to expand the work they do to give back to communities. Julie leads the TAG Oral Care Center for Excellence, whose mission is to provide free dental care to underserved adults. In 2000, the surgeon general published the first oral health report which said you’re not healthy without good oral health. It affects the overall body, and we have a lot of research that has demonstrated a systemic connection between oral health and other chronic conditions – heart disease, hypertension, and diabetes. Approximately one-third (30-34 percent) of older adults have lost three to six teeth, which has direct implications on their overall health and nutrition (e.g., risk of malnutrition, if they have dentures, they need to avoid raw fruits and vegetables).
Q: According to a Kaiser Family Foundation report published in 2021, about one in six Medicare beneficiaries reported in 2019 that there was a time in the last year that they could not get dental, hearing, or vision care, and among those who reported access problems, the cost was also a significant barrier. I invite each of you to share a bit about why we are seeing this trend in older populations, foregoing access to these services?
JFH: Affordability is definitely an issue. We know that dental utilization strongly correlates to dental insurance needs. Two-thirds of adults with private insurance over the past 12 months have had a dental visit, however, only one-third of those without have had the same access. The Illinois Department of Public Health is measuring people’s access to oral health services. Two things that they are specifically looking at are tooth loss and affordability. Another key challenge is education. Having basic health literacy is one aspect, but it is also about understanding the value of your oral health. For example, preventing that first tooth from decaying over one’s life span, can change their trajectory. There also needs to be more interprofessional valuation of oral health, and more collaboration.
PG: Similar to the issues in dental, people are not utilizing vision services because the cost is a barrier. Routine care is not covered, and patients have to come up with unique ways to pay for it. Pain is not associated with vision loss, so people put it off because they are not experiencing any pain and, in some cases, they may not even realize it is happening. There is, however, a loss of independence because if you don’t get regular vision care, you might even be able to drive to get to that care. Educating people is helping them realize if they need eyeglasses or if the problem is more severe. It is also important to educate providers to make referrals because finding specialists is challenging, and sometimes there are no providers conveniently available.
NR: Less than 20 percent of adults with hearing loss own and use hearing aids. Hearing aid sales numbers are increasing but the story is different if you look at subcategories – it is very disparate by demographics such as race and socioeconomic status. It is not just about the money either, there are access issues or barriers within the current model of hearing care. The model is based on a gatekeeper model – perhaps it’s time to start thinking about decoupling it. There is a stigma and awareness issue as well because people don’t realize if they have a hearing loss issue. If you don’t hear something you don’t know you are missing it. Hearing health literacy is important, and there is no equivalent to visual acuity. We know what 20/20 vision is, but we don’t have a benchmark where the public can gauge what level of hearing they have. We need to consider ways of engaging the public and also getting past the stigma of hearing loss that exists.
MM: There have been a lot of lessons learned during the COVID-19 pandemic. Wearing masks opened the opportunity to diagnose and identify hearing loss. Previously, a patient that was only hearing fragments of information could read lips for the rest of the message. When the provider is wearing a mask, they could no longer do this. From this observation, service providers were able to detect a few more cases of hearing issues.
MV: There are still major coverage gaps because dental care is not an essential service for adults. The Affordable Care Act (ACA) did expand dental to kids, but not to adults. Even with coverage for those who do have those benefits, there are still barriers. Medicare Advantage plans have some dental benefits, which usually only cover cleanings, and not other services needed (e.g., services to manage gum disease). We are at a moment where we need to revisit the essentialism under the law for these three services. “That’s how you address this in my view.”
There are large health equity issues at play here as well. We have found that for many indicators, disparities are widening for seniors by race and income, and that problem is only getting worse. For children, it has been a compulsory and essential service, included in the Children’s Health Insurance Program (CHIP). The lack of comprehensive policy changes continues to amplify disparities and any change.
NR: The Over-the-Counter Hearing Act in 2017, gave the FDA three years to create regulations for hearing aids for more mild and moderate cases. There are 38 million Americans with some hearing loss, and of those close to 94-95 percent are mild. Those cases could benefit from a direct-to-consumer pathway that is regulated. This legislation introduces a way for companies to get into this market. Right now, there are only five companies dominating the space with ownership of thousands of clinics as well. They are drugmakers, pharmacists, and physicians all-in-one, with high costs in volume and zero new entries.
We needed to do something to bypass this model. Hearing care used to be a fence with two sides, now there is a pyramid approach with new entry points. We can begin to meet people where they are, even if not by any gold standard, there still may be some improvements if they can get an over-the-counter option. There are not any older-adult-friendly hearing aids currently with some of the technology barriers, but rebuilding the model within a new system could change that by opening the door for innovation.
Q: How do you incorporate behavioral, mental health challenges, and social determinants of health into your work?
MM: We universally screen patients for social determinants of health (SDOH). We do not wait for them to get around to saying something that indicates a barrier, but rather asks them directly. We prioritize these things at a population level, making sure not to neglect the personal care level of needs. One of the most commonly identified SDOH is food insecurity. You have to address that first because if someone is trying to think about accessing food daily, they won’t be paying attention to you addressing their vision, dental, or hearing needs.
PG: They also screen clients, and the most common needs are often housing or employment. When they are not able to provide services to address these needs internally, they tap into their community partnerships for referrals. They also have psychologists on staff so they can provide supplemental social services, because people can’t use the health for their vision, hearing, or dental if they are dealing with a mental health issue.
JFH: The center is also screening for SDOH. Twenty-eight percent of their patients can drive to the center, and everyone else has challenges with transportation. They are figuring out how to address this. Oral health can have an impact on emotional health and wellbeing (e.g., not smiling, avoiding social activities, and feeling embarrassed, which is likely a similar issue to hearing and vision with different attributes).
Q: As we approach the mid-term elections, what policy agendas are you looking forward to seeing addressed?
NR: The hearing care expansion under Medicare that was included in the Build Back Better final draft was a good step. Over-the-counter hearing aids are happening, and now we need to cover services to support everyone so that people have access to an audiologist under Medicare.
MV: Momentum is building for adding dental as a core service in Medicare. It’s not a question of if, it is a question of when – maybe a 5–10-year time horizon. Overall, these are the next three areas to be addressed in health policy issues. If something happens sooner, I hope we don’t simply copy dental insurance in the private sector. We should use the model that was used for children’s dental via the ACA as these have really worked. We should treat these issues like core health care and whatever is medically necessary is covered. And we should also reward providers for providing better outcomes.