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Aware that there are many reasons why Medicaid patients may not receive sufficient dental care, efforts to overcome the problem take many different approaches and are meeting with success in communities across the United States.
William Mercer consultant Ben Schechter, DDS, tells State Health Watch that "the problem is that there isn’t just one problem. There are regional and cultural issues that can interfere with receiving needed dental care." While the problem discussed most often is the inadequate level of reimbursement for participating dentists, Mr. Schechter says, people are learning that an infusion of money isn’t enough to ensure greater access and utilization.
"Many people on Medicaid are relatively new immigrants to this country who have never been to a dentist," Mr. Schechter explains. "Or they have been here for a longer time but are part of a culture that views dental care as unimportant and believes that the only time to go to a dentist is to have a tooth that hurts pulled out." Other issues include:
The concern about Medicaid dental care and potential solutions for improved access and utilization were discussed earlier this year at the sixth Congress on Medicaid & Medicare produced by the National Managed Health Care Congress.
"There’s no one solution that will work everywhere," Mr. Schechter says. "But there are ways of looking at all the causes and chipping away at the problem. Some states such as California and Ohio have significantly increased reimbursement for dentists and other states have tried to move the Medicaid population into the private sector with HMOs that contract with dental vendors."
Some managed care companies have worked on creative solutions, he says, with sponsors providing additional funds that can be used for things such as transportation, school screenings, and even renting dental offices and their staffs for one day a week and then busing patients to the office.
Realizing the importance of starting good dental health with children, Michigan has experimented with a program in which Medicaid children are placed in commercial products as if they were non-Medicaid patients. Dentists are paid according to the fee-for-service contract they have with the commercial company whose card the children carry.
"It appears that utilization is up significantly and that both dentists and patients are happy with the system," Mr. Schechter reports. "I understand it is pretty expensive, however, and I haven’t seen a breakdown in the cost increases between higher utilization and higher reimbursement."
Because many of the problems seen in Medicaid dental care are the same as those in Medicaid medical care, Mr. Schechter contends that solutions often must be found at the community or county level, when local leaders assess their specific problems and the resources they already have available and bring those resources to bear to solve the problems.
One place where access and quality of care is being improved is in California through efforts spearheaded by San Francisco-based Delta Dental of California. Delta Dental senior vice president for state government programs Michael Kaufmann tells State Health Watch that barriers to care that have been identified within the Medicaid population include cultural and linguistic differences, geography, transportation, and awareness. On the provider side, there are concerns about compensation, submission requirements, Medicaid population issues, and a shortage of specialists.
Delta Dental has worked with other stakeholders on solutions for many of these problems. For instance, where not enough dental practices are available to take Medicaid patients, Delta has helped organize mobile vans, inclusion of dental services in rural medical clinics, and making services available through the state’s five dental schools. "We need to find ways to get services to Medicaid beneficiaries so we don’t have to wait for them to come to us," he says.
Problems with provider availability are being addressed through having dental students work in rural clinics as part of their clinical rotations, bringing post-doctoral endodontics and pediatric practitioners to rural clinics, and recruiting new providers.
Because special skills are needed in working with pediatric patients, Delta holds classes for interested dentists who haven’t had that specialized training, and also helps family physicians learn how to identify potential oral health problems and know what resources are available for referrals.
Working with other community-based agencies, they participate in health fairs and other activities to increase awareness of the need for good oral health and the resources that are available to Medicaid patients. And they sponsor focus groups with patients so they can better analyze the barriers and find effective ways to remove them.
Cultural and language problems are addressed by translating program materials, maintaining a provider office profile database so culturally appropriate providers can be located, offering a multilingual telephone service, and participating in community relations programs.
Mr. Kaufmann says that while Delta Dental believes it is doing the right thing and therefore has not been overly concerned with evaluating the efforts, they have looked at changes in utilization and believe they have been able to make "major inroads to draw higher utilization. The numbers we see are pretty high when compared with general utilization in other states."
States interested in learning from and replicating Delta Dental’s California success should be looking for ways to make better use of the resources they have available to them, since it often is not possible to increase fees to the customary level, Kaufmann says. "You need to focus on the reasons why beneficiaries don’t get care and try to develop solutions community by community," he says. "We always start with the local provider community and see if they are able to take more Medicaid patients. If they can, we find ways to get the patients to them. If they can’t, we find ways to make additional resources available."
Mr. Schechter says that while funding is an important issue, it’s not the only issue and sometimes can be used as a cop-out.
"You have to be willing to take the money that is available, or maybe with a small increase, and leverage what you can do with it by bringing some creative solutions," he says. "The key is to work at the city or county level rather than trying to make changes systemwide. Use the infrastructure and resources that are already there and learn how to marshal them more effectively. Don’t give up. There’s a lot that can be done to break down barriers and use the available resources more efficiently.
[Contact Mr. Schechter at (216) 292-6102 and Mr. Kaufmann at (916) 861-2301.]