Fiscal Fitness: How States Cope: States improving Medicaid dental care Community and provider support key to success
Fiscal Fitness: How States Cope
States improving Medicaid dental care Community and provider support key to success
Some states are experimenting with new ways of delivering dental care to Medicaid patients and reporting good results.
In Rhode Island, an oral health access project funded by the Robert Wood Johnson Foundation through the Center for Health Care Strategies led to design and implementation of the RIte Smiles program. Theprogram goal was to improve access to dental care for children enrolled in Rhode Island Medicaid.
The Oral Health Access Project partnered with Rhode Island Foundation and Rhode Island KIDS Count and awarded performance-based grants for 15 different projects that were key building blocks to increase access to dental care for the state's most vulnerable populations.
Rhode Island Department of Human Services oral health project manager Martha Dellapenna tells State Health Watch the grants developed access to school-based oral health services in core communities, enhanced safety net dental clinic capacity in underserved areas, and addressed work force issues. Under the program, she says, a pediatric dental residency program was expanded, a general residency program was launched, 11 residents were added at two Providence inner-city hospitals, and a 10-week dental assistant training program was established for parents on welfare who are returning to work.
Needing to remain budget-neutral, Rhode Island obtained a Section 1915(b) Medicaid waiver from the Centers for Medicare & Medicaid Services and used an experienced Medicaid dental managed care organization for value-based purchasing that focused on prevention and primary care to avoid costly dental procedures long term.
RIte Smiles has the same dental benefits as Medicaid fee-for-service, Ms. Dellapenna says. There are no copays or premiums for families to pay, and enrollment in the plan is mandatory for eligible children born on or after May 1, 2000. The plan contracted with United Healthcare Dental, which offered a statewide network of participating dentists and dental specialists to choose from, as well as claims processing, customer service, and provider relations services, and coordination of transportation and interpreter services as needed.
Short- and long-term savings
Short-term savings in the Rhode Island program were achieved by changing the state's Medicaid orthodontia criteria. Ms. Dellapenna says long-term savings will be achieved by getting children into the dentist for early and regular care and education and prevention to decrease incidence of dental caries and more serious dental conditions.
By the end of last year, the state had expected to enroll some 30,000 children in the program. The number of actively participating dental providers went from 27 to about 160 and continues to increase. And reimbursement rates were increased to be more in line with the prevailing commercial PPO rates in the state.
Keys to success
Ms. Dellapenna says the keys to the program's success include taking a client-based approach, implementing RIte Smiles without additional money in a time of fiscal austerity, very strong community collaborations and partnerships, support from the dental provider community, and dental society and legislative support. Often, she tells SHW, dentists were not accepting Medicaid patients because of inadequate reimbursement rates. "We told the vendor we needed better doctor participation," she says. "The rates are now close to the prevailing commercial rates and the doctors tell us the new rates are fair, despite being discounted." Ms. Dellapenna also says United has done a good job in working with dentists on the best ways to treat very young children as patients and on cultural issues.
She says the vendor managed to create a lot of excitement among providers to be part of the new program. As a result, providers were expecting increased volume of patients and that was slow to develop because it took time to educate parents on the idea of bringing their children to the dentist.
Apple Tree meets special needs
In Minnesota, Apple Tree Dental, a private, nonprofit dental organization that has been operating for more than 20 years has been working to improve the lives of people with special dental access needs. Apple Tree provides dental health services, community leadership, and education, all flowing from a vision that says: "We believe that oral health is a basic human right and needless suffering must be eliminated. We envision a future where everyone from the very young to the very old are able to obtain the care they need."
Solving access problems
Apple Tree's Twin Cities director of dental services Jayne Cernohous tells State Health Watch the program combines government-funded programs with private programs and nonprofit grants to provide preventive, restorative, surgical, and prosthetic services through a central clinic and a mobile program involving six mobile offices, 15 Head Start centers, 75 long-term care facilities, two schools, and eight group homes. She says many patients are seen where they live through the mobile clinics. Facilities that realize they have a need contact Apple Tree, she says, and Apple Tree arranges to provide mobile services if it appears it will work.
Ms. Cernohous says Minnesota's dental access problem can be seen in statistics showing that 30% of 600,000 enrollees in public health programs see a dentist in a 12-month period and only one-third of the state's dentists provide more than $10,000 in services to public program patients, with one-quarter of the dentists seeing no public program patients at all. One reason is that public programs pay less than 50% of the average billed charges. The majority of patient complaints about access to the state ombudsman's office involve dental access, even though dental care is less than 2% of the health care budget.
In response to a state request for proposal, Apple Tree was awarded a planning grant for what is known as the Oral Healthcare Solutions Project. The project's goal was to design a new oral health care system to deliver improved oral health care and contain the cost per person treated. Apple Tree and the state have been working to obtain needed federal waivers for a model that Apple Tree would likely run.
Money spent questionably
Ms. Cernohous says the old Medicaid model spends more than half on diagnosis and prevention and less than half on all other dental care. The Medicaid model also promotes costly and questionable utilization patterns, she says, such as twice-yearly checkups and pumice prophylaxis for children, as well as systematically neglecting vulnerable adults and elders and failing to provide adequate access for low-income children.
The new system, she says, aims to reduce costs by: 1) providing less costly education, prevention, and screening services; 2) optimizing new roles for all providers; 3) optimizing frequency of diagnosis and effectiveness of treatment; and 4) reducing indirect costs.
Meeting patients', dentists' needs
The program provides patients a single point of contact and a virtual dental home through a help center. There are multiple points of entry and treatment. Existing dentist-patient relationships are unaffected, and existing health plan medical coverage is unaffected.
For dentists, Ms. Cernohous says, the program addresses their five leading complaints by providing higher reimbursements, from 65% to 85% of the usual, customary, and reasonable payment; assistance from the help center to prevent no-shows, no denial of payment with "respectful referrals;" no managed care commercial links, published reimbursements, minimal administrative barriers, and a trusted source of prompt payments; and multi-step procedures paid with "respectful referrals." Other concerns the program addresses include the freedom to control participation level, the freedom to offer alternative treatment options, and the freedom to participate as "specialists."
Ms. Cernohous tells State Health Watch that Apple Tree's success in the last 20 years relates to having a good idea of what services populations need, researching before opening a facility, and working with advocacy groups. "We're here for patients who have no place else to go," she says. "We don't want to displace people who are being served well.
Information on RIte Smiles is available online at www.dhs.ri.gov. Contact Ms. Dellapenna at (401) 462-5300. Information on Apple Tree is available online at www.appletreedental.org. Contact Ms. Cernohous at (651) 238-6529.
Some states are experimenting with new ways of delivering dental care to Medicaid patients and reporting good results.Subscribe Now for Access
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