“Can you imagine a time when we fully incorporate mental and dental health into our thinking about health? What is it about problems above the neck that seems to exclude them so often from policy about health care?”
That’s what Institute of Medicine President Harvey Fineberg asked in 2009. On April 8th the IOM released a new consensus committee report, “Advancing Oral Health in America”. That committee’s 2011 response to Dr. Fineberg was essentially—“not this time—change starts here.” I had the great privilege of participating on that committee along with 14 others from a variety of backgrounds and expertise. Certainly, we were daunted by the enormity of the nation’s oral health challenge but also hopeful that there are, in fact, tools and approaches that could begin to make a difference.
The IOM convened this committee based on a 2009 HRSA request for recommendations on a potential HHS oral health initiative. The committee deliberated for almost a year while the long and contentious health care reform debate reverberated. The specific charge for this committee was relatively narrow: to provide strategic recommendations to HHS, specifically, regarding a department-wide oral health initiative. Nevertheless, the national health care reform debate only served to highlight the concurrent need for reform in both oral health as well as health care, overall.
And there were a few ghosts in the mix, so to speak—namely past reports, statements, actions, initiatives in oral health—good faith efforts all—juxtaposed against the harsh fact that the problems remain. More than 10 years prior, the surgeon general issued a landmark report entitled, “Oral Health in America”. It described the poor state of oral health as a “silent epidemic”. Unfortunately and in spite of that warning, that epidemic remained altogether too silent. In fact, arguably, nothing fundamentally has changed in those 10 years. Entirely preventable oral diseases remain prevalent. Oral health is part and parcel of overall health care—but the professions treat them as distinct and separate. Vulnerable groups continue to suffer from disparate oral health outcomes.
Even potentially more disturbing—we now recognize we’re essentially “flying blind” when it comes to the quality of oral health care. Literally, we simply do not know much about the quality of oral health care for a variety of technical and policy reasons. We don’t have great data sources for oral health care measures. Even if we did, we do not have quality metrics to assess the quality of oral health care. That’s fairly worrisome if one extrapolates from the overall health care experience in quality measurement and improvement. In overall health care, once we started measuring the quality of that care, that’s when the scope of safety and quality problems—not to mention cost and value issues—really began to surface. In oral health care right now, we don’t even know what we don’t know. More to the point, there’s no reason to think oral health care will be different than overall health care—and it could be worse—much worse. In any event, it’s not acceptable to assume high quality in oral health care. The public and our dedicated health professionals deserve to know.
So, the stakes are high—this report on improving oral health absolutely must be different than past efforts—but how?
The committee reviewed mountains of evidence, testimony, and specially commissioned reports. From that evidence, the committee provided seven recommendations to the Secretary outlining specific steps to change the way the department approaches oral health as a governmental agency—and the way the department helps promote and lead improvement in the nation’s oral health. Those recommendations ranged from (1) specific things the department should do to prioritize efforts—including an explicit challenge to open the initiative to patient and consumer participation, oversight and leadership; (2) an emphasis on strengthening prevention, promoting health literacy, and dramatically improving the ability and capacity of the health professions to address and improve oral health; (3) a focus on developing innovative new delivery system and payment strategies to support high value oral health care; (4) concerted efforts to use an ever expanding array of data for research—and, importantly, to develop and construct a range of oral health quality measures on performance, cost, efficiency and outcomes—and then make that information transparent and useful; and finally (5) an explicit challenge to HHS to hold itself publicly accountable year after year for action and improvement.
Of course, only time will tell if some new group 10 years hence looks back on this report as a turning point in improving the nation’s oral health—or says nice try, back to the drawing board. We on that committee sure hope that the answer is—and the nation critically needs it to be—the former.
[These comments are the personal views of Dr. Painter and do not represent a statement by the IOM.]
Michael W. Painter, J.D., M.D., is a physician, attorney, health care policy advocate, and 2003-2004 Robert Wood Johnson Health Policy Fellow. He is currently senior program officer and a senior member of the RWJF Quality/Equality Team.