INTERVIEW: “I will be examining the effectiveness of school-based caries prevention programs”

Dental Tribune International

Thu. 12. December 2019

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School-based oral health programs are vital to ensuring that the oral health of a country’s youth population remains of a good standard. However, as with any system, it is often a good idea to investigate the finer details in order to check whether any improvements can be made. In a recent interview with Dental Tribune International, Dr. Shulamite Huang, a health economist from the Department of Epidemiology and Health Promotion at the New York University College of Dentistry, spoke about her current study on the effectiveness of school-based cavity prevention programs.

Dr. Huang, what is the main objective of your study? When you talk about examining the effectiveness of the school-based oral health program, what do you mean exactly?
My primary goal is to assess what types of school-based caries prevention programs are most efficient and effective from a public health and state Medicaid perspective. Preceding this, we plan to evaluate whether school-based caries prevention programs are reaching their target population effectively. The results of this evaluation should be available within the next year.

Specifically, I will be examining the effectiveness of the school-based programs and their impact on oral health and health outcomes. However, I will be examining not only effectiveness on health but also cost-effectiveness. This will answer the question of whether improvements in health outcomes are worth the change in cost.

How do the current school-based oral health systems work?
School-based cavity prevention programs are largely targeted at decreasing the income disparities that affect children’s oral health. By providing clinically effective preventive dental care that can be reimbursed primarily through Medicaid, the idea is that barriers to care for the patient (i.e., time and financial cost) and barriers to care for the provider (i.e., resistance to adopting and using new clinically effective dental prevention procedures in dental practices) are addressed at the same time. Currently, school-based sealant programs that focus on first molars are recommended, but how these sealant programs compare to other types of school-based programs is unknown.

What methods will you be using to conduct your research, and do you already have an idea about how to improve the current system?
I will be using a combination of causal inference methods from economics (econometrics) and mathematical modeling methods for economic evaluation. This is the first study, to our knowledge, that can track both Medicaid dental care utilization and expenditure with clinical oral health outcomes over time across study participants. Prior studies have relied on mathematical modeling to extrapolate long-term outcomes and impact on dental care expenditure.

Regarding improvements, there needs to be more done to evaluate novel models of delivering and financing dental care. I co-authored a paper a while back that found that the financial incentives for clinically effective prevention are perverse—dentists are generally reimbursed more for clinically ineffective dental prevention than for clinically effective prevention. At the same time, dental insurers also may not have strong incentives to change how they reimburse. As a result, the question of how best to reimburse for and incentivize the adoption of clinically effective dental prevention is still unanswered. My work is a follow-up to this earlier American Journal of Public Health paper, which proposes that school-based delivery of clinically effective dental prevention can be a way to circumvent issues of restructuring reimbursement to private dental clinics.

In America, nearly 30% of school-age children and 50% of rural children are affected by cavities. Will you be specifically investigating this area?
School-based caries prevention programs attempt to improve oral health outcomes among children at high risk for caries. By delivering care to children where they are, we’re able to diminish the barriers to caring for children, such as the time the parents must take off from work and travel costs for visiting the dentist. The availability of low-cost procedures that can address active decay, such as the application of silver diamine fluoride, can also prevent any out-of-pocket costs for treating that tooth in a clinical practice. However, how to implement school-based caries prevention programs in a way in which they fit into the Medicaid budget is a question that I’m seeking to answer through my K25 grant.

Will you be touching on universal health care?
This grant touches indirectly on universal health care. One of the things we really want to understand is whether implementing school-based caries prevention programs will actually save Medicaid state programs money in the long run. If they do, then this can be a strong argument supporting universal school-based caries prevention.

Editorial note: The American Journal of Public Health paper referred to is titled “Getting the incentives right: Improving oral health equity with universal school-based caries prevention.” It was published online in the June 2017 issue.

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