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Filling the gap in oral health care for Worcester’s underserved

Meet John Gusha ’80 a dentist-activist who is dedicated to giving a healthy smile to those who can’t afford it

By Joan Killough-Miller Photography by Patrick O’Connor

In 2003, the Robert Wood Johnson Foundation selected John Gusha as one of 10 honorees to share a $1.2 million Community Health Leadership Program award, for his “exceptional and effective approach to addressing the myriad health-care challenges facing people in communities across the United States.” It is the nation’s highest honor for community health leadership.

“A State of Decay.” That’s what the Massachusetts Society for the Prevention of Cruelty to Children called its 2004 report on the commonwealth’s oral health-care system, which leaves the majority of Medicaid-eligible children—about 380,000—without dental treatment.

“Worse than a third-world country” is how Holden dentist John Gusha ’80 describes the epidemic of dental neglect that festers in his own backyard. Worcester’s unfluoridated water, along with sugary snacks, creates special concerns for the city’s children, he says, adding that two out of three students seen in public school screenings suffer from untreated decay, with an average of three to four cavities each. This contrasts sharply with the private-pay patients he sees at his Holden office. “In Suburbia USA, where I practice, I see very little decay in children’s teeth, due to fluoride. Those kids are being raised so that by the time they’re 30, probably 90 percent won’t have a filling in their mouths. That discrepancy has got to be addressed.”

From plaque to politics

Five years ago, Gusha brought together local dentists and nonprofit agencies to form the Central Massachusetts Oral Health Initiative. Through CMOHI, he has received $3.6 million in grants (his major sponsor is the Health Foundation of Central Massachusetts) to fund ongoing programs, including fluoride varnish treatments and dental screening programs in 21 area schools. In addition, CMOHI has invested about $400,000 in a public awareness campaign on the fluoride issue.

“When we started the initiative, we sat down to discuss solutions,” he says. “It all came down to things that happen on a global level—problems with the Medicaid system, legislative issues, and awareness about oral health—as opposed to, ‘How do I get a dentist to fill this cavity?’ Dentists are willing to do their part.” [The American Dental Association estimates private dentists provide an average of $36,000 in free or discounted care given each year.] But, Gusha points out, “It’s easier to volunteer abroad than it is to serve the needs that exist here in Central Massachusetts.” Friends who have served in third-world countries tell him, “John, I can do brain surgery over there, but they won’t let me fill a tooth here without CORI [background] checks and an impossible amount of credentialing, even though I’m already licensed as a private-practice dentist!”

To remedy a critical shortage of dentists available to patients on MassHealth—the state’s Medicaid program for children from low-income families and foster children—Gusha is working for reforms. “In Worcester County, there are only a handful of private dentists who accept MassHealth—and no one wants to be added to the list,” he says. “The problem is, if I take one Medicaid patient, by law I have to accept every Medicaid patient who requests treatment. I would be inundated with phone calls.” With reimbursement rates lower than the actual cost of care, he says, “I couldn’t stay in business.”

“Caseload cap” regulations in other states allow dentists to limit the number of Medicaid patients they accept. Gusha has been working for years with Massachusetts state senator Harriette Chandler to implement a two-year pilot program to test the impact in Worcester County. With 300 private-practice dentists in Central Massachusetts, Gusha says, “If everyone took a little bit, it would help the problem immensely.”

The state’s maddeningly inefficient processing of claims also needs reform. “Dentists would rather work for free than struggle with the MassHealth system,” Gusha says. “Dentists aren’t going to sign up for a program that keeps denying claims and has them writing letters all the time just to collect a $15 or $20 payment. It’s just not worth it.” That’s why he’s also pushing for a private, third-party administrator (TPA) to process claims, a solution that has helped in other states.

“When we started the Oral Health Initiative, we sat down to discuss solutions. It all came down to things that happen on a global level—problems with the Medicaid system, legislative issues, and awareness about oral health—as opposed to, ‘How do I get a dentist to fill this cavity?’ ”

Drilling home his message

Gusha’s first efforts—a free clinic in a church, where volunteers used flashlights to peer into patients’ mouths—has evolved to advocating for structural change on a statewide level. As a faculty member at the University of Massachusetts Medical School in Worcester, he is among a group of dentists and physicians who are developing a dental residency program that will help integrate oral health into the medical curriculum and provide a much needed dental presence in Worcester’s hospitals.

He devotes one day a week—time taken away from his private practice—to meet with state legislators, write grants, and work to convince the public that fluoride is as essential as childhood vaccinations and that dental care is not a luxury, but a “mainstay” of overall health.

Momentum for change is growing, and recognition from the Robert Wood Johnson Foundation has helped Gusha gain the ear of Rep. James McGovern (D-MA) and senators Edward Kennedy (D-MA) and John Kerry (D-MA). “The phone calls get answered quicker now,” he jokes. Although Gusha is often put in the media spotlight, he points to the many heroes—dentists, educators, and politicians—who have rolled up their sleeves for this battle. “I could certainly work full time on this problem,” he says. “We could use a dozen people working on it. All you can do is hope to make a difference.”

In the meantime, the majority of low-income children go without routine care that would prevent serious problems down the line—even though federal law requires Medicaid dental coverage for children from birth to age 21. “To let this generation grow up with as much decay as is in their mouths is criminal neglect,” says Gusha. In fact, the advocacy organization Health Care for All has filed a class action suit against the commonwealth for failure to provide adequate dental services to Medicaid-eligible children.

For adults, the safety net is even thinner. Two years ago, Medicaid eliminated all dental care for people over 21. Adults with acute problems might resort to the emergency room, only to be given a prescription for an antibiotic or painkiller and referred to one of Worcester’s two community health centers. “There they’ll find a waiting room full of people, and two dentists dedicated to treating emergencies all day long,” says Gusha. “It’s first come, first served, with waiting lists of up to a year for comprehensive care.” He has seen an abscessed tooth progress to a brain stem abscess and systemic infection. “It ended up costing $200,000 in hospital care that could have been prevented by treating a cavity three years before,” he says.

Making a difference—statewide, or in the life of an individual—is what keeps Gusha going. He recalls one teenager who came to a Worcester clinic for treatment from a rural town at the western reaches of the county. “I’m looking at his chart, which has red marks indicating decay, everywhere,” Gusha says, “and I’m trying to figure out where to start. From behind the chair I say, ‘OK, Billy, what can we do for you today?’ and he turns to me and says, ‘Doc, I can’t get a date!’ He gives me a big grin; I see that his teeth are broken down right across the gum line. I worked on him for three hours and was able to build up all his front teeth. Though he needed to come back for root canals and other work, we were able to give him a smile that day.”

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Last modified: Apr 13, 2005, 11:58 EDT
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