improving oral health: strategies for increasing available
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Improving Oral Health: Improving Oral Health: Strategies for Strategies for
Increasing Available Increasing Available ProvidersProviders
H. Bryan Tomlinson, II, Director of Health Care Services
Virginia Department of Medical Assistance Services
National Association of State Medicaid Directors2007 Fall Conference
Washington, DCNovember 13, 2007
2
Virginia Virginia Medicaid/SCHIP Medicaid/SCHIP Dental BenefitsDental Benefits
Approximately 490,000 eligible childrenApproximately 490,000 eligible children
Dental benefits for children in Dental benefits for children in Medicaid/SCHIP include:Medicaid/SCHIP include: Diagnostic, preventive, restorative/surgical Diagnostic, preventive, restorative/surgical
procedures and orthodonticsprocedures and orthodontics
Dental benefits are not covered for Dental benefits are not covered for Medicaid adults, except for limited oral Medicaid adults, except for limited oral surgery (e.g. extraction of infected teeth surgery (e.g. extraction of infected teeth complicating a medical condition, etc.)complicating a medical condition, etc.)
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Access to/Utilization of Access to/Utilization of Dental Services Needed to Dental Services Needed to
ImproveImprove
In FY 2003, 23.4% of In FY 2003, 23.4% of eligible children eligible children received servicesreceived services
Low participation of Low participation of all VA licensed all VA licensed dentists (620 of dentists (620 of 4,786) in the 4,786) in the Medicaid/ FAMIS Medicaid/ FAMIS programprogram
87%
13%
Not Participating
Participating
Dentist Participation in Medicaid/FAMIS*
*FY 2003
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DMAS Dental SurveyDMAS Dental Survey
Survey was developed to identify the Survey was developed to identify the reasons providers did not want to reasons providers did not want to participate in the Medicaid/FAMIS participate in the Medicaid/FAMIS dental programdental program
Survey was mailed to all licensed Survey was mailed to all licensed dental practitioners in Virginia (over dental practitioners in Virginia (over 4500) in 20044500) in 2004
Over 1000 surveys were completed and Over 1000 surveys were completed and returned to DMAS. (22% response rate)returned to DMAS. (22% response rate)
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Barriers to ParticipationBarriers to Participation
ReimbursementReimbursement Claim SubmissionClaim Submission Prior authorizationPrior authorization Timeliness of paymentTimeliness of payment Availability of specialistsAvailability of specialists Patient behaviorsPatient behaviors
Broken appointmentsBroken appointments Non-complianceNon-compliance
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Would you consider Would you consider participating if fees participating if fees
increased?increased?
0
10
20
30
40
50
60
70
80
Per
cent
age*
Yes
Yes, if other changesmadeNo
* Percentage of those that answered particular question
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Program GoalProgram GoalImprove Access to Quality Dental
Care to Medicaid/SCHIP Recipients
Increase Provider Participation
Increase Pediatric Dental Utilization
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Stakeholder Stakeholder Engagement Engagement
Advocacy Groups
MCOs
Organized
Dentistry
Medicaid/SCHIP Agency
Governor
Legislature
New Medicaid/ FAMIS Dental
Program
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A New Day for Dental! A New Day for Dental! Smiles For ChildrenSmiles For Children
Effective date: July 1, 2005Effective date: July 1, 2005
New program was labeled New program was labeled Smiles For ChildrenSmiles For Children with a new logo and registered service markwith a new logo and registered service mark
All children (Medicaid & FAMIS) were enrolled All children (Medicaid & FAMIS) were enrolled in a single program administered by Doral Dental in a single program administered by Doral Dental USAUSA
Limited medically necessary services for adultsLimited medically necessary services for adults
Medicaid/SCHIP retains policymaking authority and Medicaid/SCHIP retains policymaking authority and closely monitors contractor activitiesclosely monitors contractor activities
New program is fee-for-service and non-riskNew program is fee-for-service and non-risk
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Fee-for-Service with a Fee-for-Service with a Commercial FlareCommercial Flare
Many principles of a managed care Many principles of a managed care product were adopted:product were adopted:
Coordination of Care Coordination of Care Provider CredentialingProvider CredentialingNetwork DevelopmentNetwork DevelopmentMember OutreachMember OutreachQuality Improvement Quality Improvement ProgramsPrograms
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Key Program Key Program EnhancementsEnhancements
Old Program Multiple Vendors
Multiple credentialing processes
Complicated Administration
Limited local representation on program policy decisions
Enrollee transfer between plans disrupted care
Smiles For Children Single Vendor (Doral)
Streamlined Credentialing
Easy, Industry-Standard Administration
VA Based Peer Review Committee/Dental Advisory Committee
All enrollees in Smiles for Children program
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ResultsResults
Increased Provider Increased Provider NetworkNetwork
387 new dentists are 387 new dentists are participating (62% participating (62% increase)increase)
Percentage of Percentage of contracted providers contracted providers who are billing for who are billing for services has services has increased from 50% increased from 50% to 83%to 83%
620
1007
500
600
700
800
900
1000
1100
1200
Jul-05 Sep-07
Participating Providers
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Incentives to Attract Incentives to Attract ProvidersProviders
Increased ReimbursementIncreased Reimbursement Improved ease of administrationImproved ease of administration Conformed to commercial practices Conformed to commercial practices Reduced broken appointmentsReduced broken appointments Offered superior provider relationsOffered superior provider relations Provided flexible levels of Provided flexible levels of
participationparticipation Collaborated with dental communityCollaborated with dental community
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……..And Increased Access ..And Increased Access to Careto Care
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
Ages 0-20 Ages 3-20
SFY 2005 SFY 2006 SFY 2007
Percentage of Children Receiving Dental Care
24%
29% 29%
36%
Source: CMS 416 Report for Virginia
35%
43%46%48%
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Lessons LearnedLessons Learned Reduce program requirements for Reduce program requirements for
providers who uphold high standards of providers who uphold high standards of carecare
Centralize and standardize processes Centralize and standardize processes through advanced web based servicesthrough advanced web based services
Promote best practicesPromote best practices Acknowledge dental community Acknowledge dental community
participation to state legislators and participation to state legislators and public policy groupspublic policy groups
THANK providersTHANK providers
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On-Going ChallengesOn-Going Challenges
ReimbursementReimbursement Prior program experiencePrior program experience Provider attitude towards Provider attitude towards Medicaid Medicaid enrollees enrollees
Payor environmentPayor environment Recruitment in rural areasRecruitment in rural areas
1-888-912-3456http://www.dmas.virginia.gov/dental-home.htm
http://www.doralusa.com
THANK THANK YOU!!!!!YOU!!!!!
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