By Alex McEllistrem-Evenson
For Greg Nycz, the goal is clear: “We want to end the oral health disparity between the people with limited incomes and everyone else.”
This may sound lofty to some, but it takes little more than a perusal of what Nycz has already accomplished to realize that he means business. As the director of Family Health Center of Marshfield, a Federally Qualified Health Center (FQHC), director of health policy for Marshfield Clinic in Marshfield, Wisconsin and a nationally-recognized expert in rural health, Nycz has taken the lead in his state to improve oral health access. He is one of two primary authors of a 2007 detailed proposal for action titled “Solving Wisconsin’s Oral Health Crisis,” has been instrumental in opening numerous dental clinics throughout rural Wisconsin over the last decade, and is in the process of formulating a plan and proposal for an innovative dental school designed to train dentists to practice in rural areas.
The secrets to Nycz’s success are rather simple: maintain clear, concrete goals and divide large problems up into smaller, more manageable portions. “So much of what we do all the time is putting bandages on problems that we never think we can solve,” remarks Nycz. “I’ve been working in this area for 37 years and I just kind of said that for once, I would like to tackle a problem and solve it. That’s what this is all about.”
Bridging the Gap
The Department of Health and Human Services’ 2009 National Data Summary Report, lists the EPSDT dental utilization rate (Early and Periodic Screening, Diagnostic and Treatment, page 52 of the prior link) for kids 20 and under in all states except for Hawaii and Maine, which didn’t collect data. “There were only three states in the nation worse than Wisconsin,” states Nycz. “We’re at 23%. The best state, which was best by a bunch, was Vermont at 53%. The next best state is at about 45%. In 47 of the 48 reporting states, a majority of their children on Medicaid don’t get care. In the best state in the nation, 47% of their kids don’t get care. All states are failing. They’re all failing. And we’re failing worse than many others. We want to turn that around.”
“There has been this historic differential between medical care and dental care that is not part of the community health center model,” states Nycz. “If we’re going to improve the health of our population, we need to start to bridge the gap that exists between dentistry and medicine, and we need to be able to rapidly increase access to dental services for those folks who currently lack that access.”
According to Nycz, that process begins on the medical side of the equation. “There’s a role for physicians who see children a lot more frequently to educate parents and others about the importance of oral health,” he claims, and believes the “gap” he refers to can be bridged in part through the use of integrated electronic records systems, which would allow physicians and dentists to communicate with each other about the needs and histories of their common patients.
Beginning in February, clinics under Marshfield’s umbrella will begin using the electronic records system Nycz advocates. “It is probably the most comprehensively-integrated medical and dental record in the nation,” Nycz continues. “If our dentists have an HIV, AIDS, or [otherwise] complex patient who’s also a medical patient of ours, they can take a look at the medical records very easily. If they’re on a blood thinner, they will be able to find out soon what the last lab results were, all with a few simple punches of the keyboard. Our physicians will be able to look at what’s going on in the dental offices as well.”
That’s not all, however. “There are a number of things we need to do,” Nycz adds. “We have to set up a lot of dental clinics, hire a lot of dentists, and we have to be sure they take care of everybody based on need, not ability to pay. We’re certainly going to take all Medicaid without limits and we have to set up a sliding fee for uninsured low-income people to bring it within their means, so if they don’t have any insurance and are living in poverty, we have to be able to provide them that care at a free or nominal rate; if they’re between 100 and 200 percent of poverty levels, we have to find a way to give them significant discounts so that we can price the service within their means of achieving it.”
These may sound like pipe dreams, but Nycz and his partners have already made significant progress. “We’re well-along on this,” he explains. “One of our first clinics opened in 2003, and I believe that within a year or two we will have eliminated the oral health disparity problem in that county. The second county will be close behind that. In fact, I actually have hope that we will go beyond eliminating the disparities to actually having our low-income children and adults in those communities accessing dental care at rates above the national average for people who are not poor.”
The first clinic established under Nycz’s plan attracted patients from all over the state. Using what Nycz calls a “picket fence” model, each clinic focuses increasingly on the local patient base as more clinics are opened elsewhere. “Every time we open up a clinic, the penetration rate to the underserved population under 200 percent of the poverty level jumps,” raves Nycz. “Even though we’re not the sole provider in the zip codes close to that clinic, we’re [handling] over 40 percent of everybody under that poverty level. To eliminate the oral health disparity, we need to get to about 65 percent.
Three clinics have been established to the South, East, and Northest of the first one thus far, with one more on the way. Nycz remarks that each new clinic increases the aforementioned penetration rate by another ten percent. “When we open the clinic to the west [in July 2010], we have an opportunity to eliminate or reverse the disparity,” he states.
Despite the fact that most of the patient base at these clinics is rural, Nycz is very confident that if his initiatives continue to succeed, they can serve as a model for the nation. “This is an area in Wisconsin that has a comparable amount of Medicaid kids to about five of the lower-populated states combined,” he states. “We want to show that we can take [the percentage of children on Medicaid receiving dental care in] this area of the state beyond Vermont,” which had the highest rate in 2007. “If we can do it here, then we can do it elsewhere.”
All of these initiatives, however, are highly contingent on the availability of dental workforce. “We just opened up our sixth dental clinic, we are breaking ground on our seventh and eighth clinics, and we’ve got plans to open our ninth and tenth dental clinics by the summer of 2011,” states Nycz. “We’re well on our way on this journey, but we’re opening our dental clinic in Medford with only two dentists, and we still need dentists in Chippewa Falls. We’re having a great deal of difficulty finding the dentists we need.”
Nycz doesn’t equivocate: “We are trying to do something that really hasn’t been done anywhere else, but looking at it very comprehensively, this will fail if we cannot get the workforce we need. We’re hiring a lot of high-quality dentists with a strong orientation [towards public service]; there are just not enough of them.”
As a result, Nycz and his partners are starting to talk about starting a new kind of dental school, designed to prepare students for professional service in rural Wisconsin.
Regionalizing Dental Education
“Ultimately, to achieve our goal and to have this as a model for the nation, we need to pick differently, train differently for service in a different kind of a setting,” claims Nycz. “One of the issues is that in rural areas, the traditional model of a solo doc out there is tougher and tougher to maintain. Particularly in rural communities where there’s a lot of patients on Medicare without a dental benefit and a lot of lower-income people. Dentists coming out of school with large debt loads say there’s not enough economic activity there to support a practice.”
Nycz believes that a possible solution lies in “regionalizing” dental care and dental education, housing groups of five dentists in a single facility that is also equipped to accommodate four dental students, which would work in the clinic serving a rural area as their fourth year of dental school. “Dental education is different from medical education with respect to where the students get their clinical experiences,” states Nycz. “In medicine, they farm out their students. The traditional model for dental schools, however, is to have your own clinical campus. With that model in mind, all the dental schools have to be within urban areas. We believe that’s not really serving rural interests as well as we need.”
“One of the strategic problems we have,” Nycz continues, “is we don’t have enough patients for these students [in rural areas]. If we’re going to have a dental school in a community like Marshfield which has 20,000 residents, how the heck do you get patients to the students? The answer is you have to spread the kids around.”
According to Nycz, “dental is probably the least-diversified workforce in health, so there are a lot of steps being taken by schools now [to remedy that]. But nobody has really done much in terms of rural issues – if you think about it, dental schools are all located in big urban areas because they need patients for their students.”
There are, in Nycz’s opinion, “an awful lot of programs in dental education. In terms of finances, [dental school is] one of the most expensive educational endeavors, even more expensive than medical school.” Most of these schools attempt to cope with these high costs by relying on subsidies from state and federal governments or on larger universities where the dental schools are embedded.
“AT Still [University, in Arizona] kind of broke the mold,” Nycz remarks. “They set up a dental school that can live on its tuition—even if that tuition is fairly high—so they’re not at the mercy of federal and state cutbacks or a parent university not being able to subsidize them anymore. We were intrigued by that, plus AT Still is trying to train a generation of people for service in tribal clinics and community health centers, VA health centers, and so forth where it was desperately needed. They had an idea that we could pick better if we picked the right students and trained them in a way that supported them for a career of service; that we could do better than current universities in producing students with service where they’re needed. The early results with their first three classes indicate they’ve been very successful at that, but we know that the debt burden still drives many to more lucrative practices.”
Back in Wisconsin, possible solutions to dental workforce issues are still very much in the preliminary stages. “We are looking at starting a dental school which doesn’t have a traditional centralized or clinical campus,” Nycz elaborates, “where the students would spend their entire 24 months of the third and fourth year in small urban or rural communities. We want to couple that with a kind of guarantee that says we’ll refund a portion of your tuition for every year you spend practicing in rural areas. If we can set the school up on that basis, we believe that we can achieve a higher level of accountability to the public in terms of returning more students to where they’re needed than traditional schools have been able to achieve”
Plenty of obstacles remain. “We don’t know if we can manage that because it’s all about getting the money. We’re talking about partnering with a large FQHC and possibly AT Still to set up a dental school if we can find the financing and we can deal with accreditation issues and all of that, but we don’t have approval from the Marshall clinic to do this yet. We’ve done a feasibility study, the state is going to do a feasibility study, and our first meeting is this month.”
A Model for the Nation
Perhaps one of the qualities contributing to Nycz’s success is his unique ability to visualize both the forest and the trees at the same time. “I have colleagues in Milwaukee who say ‘That’s fine, Greg, what you’re doing out there, but we could never do that in Milwaukee,’” Nycz muses. “I tell them, here’s a chunk of Wisconsin that’s about half of the state, a geography that’s mostly rural. That’s our bigger service area. Within that area, there are more people under 200% of poverty than there are in Milwaukee County. If we can do it in this area, they can do it in Milwaukee. The scale seems overwhelming, but it’s about breaking it up into smaller chunks.”
“A friend of mine, Tim Size, [Executive Director of the Rural Wisconsin Health Cooperative] has said for some time that there’s some societal problems that rural can lead on because it’s a little simpler: ‘if you can’t solve it in a town of 15,000, then all hope is gone.’” Nycz states. “In order for us to solve this problem in our state, we have to solve it somewhere within our state to show that it can be done. If you can do that, you can show that it can be replicated, and then there’s nothing to stand in between getting it done all across the state other than the resolve that’s needed and the investment that’s needed.”
“We’re going to do this one community at a time. If we can’t achieve this with the comprehensive approach we are using in our communities, then it probably can’t be done.”