children’s dental health project medicaid, chip, & healthcare reform: options and...

Children’s Dental Health Project www.cdhp.org

Medicaid, CHIP, & Healthcare Reform:

Options and Opportunities for Florida Children’s Oral Health

Burton L. Edelstein DDS MPHBoard Chair, Children’s Dental Health Project

Professor of Dentistry and Health PolicyColumbia University

Florida Public Health institute Webcast 11-5-09


Acknowledgement

The Florida Public Health Institute &The Children’s Dental Health Project have partnered to advance policies that improve children’s oral health and use of dental services


Insurance coverage for children’s dental services has been an integral part of public insurance since 1965.

Even now, it is part of Congress’ effort to reform health insurance.

Yet despite these longstanding programs, only 1-in-5 Medicaid insured children in Florida make it to a dentist in a year.

Florida’s performance serving the dental needs of low income children is one of the lowest in the country and its program for adults is limited and threatened.

It mattersIt is fixable People on this webcast can fix it!

Premise


Webcast Plan

1. The Mouth

2. The Issue: Oral health &dental care of FL’s children (all children!)

3. The Opportunities: Congressional options for states from 1965 to 2009 and what FL does with them.

4. Access versus Utilization

5. Fixes

6. Going forward: FPHI, CDHP, and you


The Mouth


An organ of– Digestion– Respiration– Communication– Protection– SexHome to unique structures– Teeth and pulp– Occlusion – Periodontium – Tongue – Salivary glands – TMJ

The Mouth: So what anyway? Why all the fuss?


The Issue:Oral Health & Dental Care of FL Children


The Problem

Kids with most needs get least care

The World of Children’s Oral Health in FL is Upside Down

Kids with least needs get most care


FL Children’s Oral Health Status

Child and Adolescent Health Measurement Initiative. 2007 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website. Retrieved [10/31/09] from www.nschdata.org


FL Children’s Oral Health Status:Parent Assessment by Age

But how well does parent assessment fit with clinical examination?


FL Parents Do Very Well Assessing Their Children’s Oral Status


Yet Problems Remain (Regardless of who you ask)


And they matter


Tooth-level impact: ECC is best predictor of future cavities. Because dental repair does not reduce disease activity, caries progression – even after repair – is common.

Mouth-level impact: ECC is a disease of the mouth that is expressed on the teeth. Unless the mouth is treated, caries progression will continue

Child-level impact: Decreased quality of life, function, mood, growth, social comfort and occasional local and distant significant infections

Family-level impact: Financial, work, and interpersonal stress

Societal-level impact: Avoidable cost demands on Medicaid, facility demands on ORs, and aggregate missed work by parents

They matter at many levels


– Dental disturbances are common & permanent

• Developmental, carious, traumatic– Periodontal disease begins

• gingivitis/periodontitis/ANUG• hormonal correlates

– Occlusion develops• esthetics & function determined

– TMJ disturbances occur• pain/dysfunction• stress, trauma, excessive use

– Oral cancer risk factors are established• Tobacco as primary risk factor

– Esthetic issues arise• Attractiveness• employability• piercing

– Eating Disorders• dental erosion, soft tissue injury

Especially for adolescents


So Who Has Poor Oral Health in FL?Oral Health by Income

1-in-6 Poor children;5 x more

than Affluent children


So Who Has Poor Oral Health in FL?Oral Health by Race/Ethnicity

1-in-8 Hispanic children

4x greater; than white children


So Who Has Poor Oral Health in FL?Oral Health by Insurance

1-in-10 Medicaid children;

2x Privately Insured Children


So Who Has Poor Oral Health in FL?Oral Health by Consistency of Insurance

1-in-8 “gap” children;

2x children with

Consistent Coverage


So Who Has Poor Oral Health in FL?Oral Health by Family Structure

1-in-6 Mom-only children;

4x Two Parent children


So Who Has Poor Oral Health in FL?Oral Health by Medical Home

1-in-10 children without a

Medical home;2x children

with Medical Home


So Who Has Poor Oral Health in FL?Oral Health by Severity of Special Needs

1-in-4 CSHCN;4x Children

without special needs


Summary of FL Children’s Oral Health

• Much like the nation’s• Tooth decay remains most prevalent

childhood disease• Profound disparities by

– Income– Race/ethnicity– Insurance status– Family Structure– Special needs– (Also by parent education, rurality, migrancy,

homelessness, immigrant and native status)


Psycho-Social

Biological

Beha-vioral

Environ-mental

Genetic

Sources of Health & Health Disparities


Newacheck 2006Fisher Owens 2007

Sources of Health and Disparities


Rethinking the Players:Roles for All!


Potential Interventions


Dental Care of Florida Children


Most underserved are young children of low income minority families whose parents have little education

Dental Care: US Picture


Children’s Use of Dental Services:FL v. US Children

1.5x more Florida parents report no dental visit in a year than do parents across the US. Which children are they?

NOYES

NOYES

j


YES VISIT NO VISIT

Children’s Use of Dental Services:FL Young children

More than half of young children have no dental visit


YES VISIT NO VISIT

Children’s Use of Dental Services:FL Multiracial children

Racial-ethnic minority children have fewer visits


YES VISIT NO VISIT

Children’s Use of Dental Services:FL Spanish language children

Spanish speaking children have fewer visits


Children’s Use of Dental Services:FL Poor children

YES NO

Half of poor children have no visits


Children’s Use of Dental Services:FL Children in Medicaid


Children’s Use of Dental Services:Parent v. Medicaid reporting

YESNO

64% of Medicaid & CHIP (Healthy Kids) Parents report that their child had a dental visit in a year

But the State of Florida reports that only 21% of Medicaid children had a dental visit in a year

Likely both over-reporting by parents and under-reporting by state and influence of Healthy Kids group

Either way far too few children are obtaining needed care

YESNO

Parents

State


FL Medicaid performance compared to other states

FY 2008 Update (CMS): 21% had a visit; 14% had a preventive visit; 8% had a reparative visit


Does lack of access explain poorer health status for vulnerable children?

Determinants of health status


1. Too many of FL’s children suffer too much, too early in life, from a preventable disease.

2. Disease is prevalent & inequitably distributed and we know where it is.

3. Primary disease determinants are not access to reparative care.

Therefore interventions are needed at two levels:

1. repair for extant disease

2. risk mitigation/disease management for new disease.

What can we conclude so far?


The Opportunities:Options Provided by Congress


Poor

Low Income Middle Class Affluent

Elders (“DUALS”)

MEDICARE (1965)

Adults

MEDICAID (1965)

EMPLOYER-SPONSORED INSURANCE

(1940’s)

Children

MEDICAID EPSDT (1967)

CHIP (1997/2009)

US Healthcare Insurance “System”


US Healthcare Insurance “System”:Dental Coverage

Poor

Low Income Middle Class Affluent

Elders MEDICARE

& MEDICAID

MEDICARE: None

Adults

MEDICAID State

Option

Children

EPDST Required

CHIP Required

EMPLOYER SPONSORED COVERAGE

Employer Option


Medicaid for Children: EPSDT

Early & Periodic Screening

Diagnostic and

Treatment

Services

• Covers children birth through18 years• Must cover children to at least 100% of poverty (higher for under 5)• Individual entitlement• Mandatory on states• Paid by states and federal government• No copayments or cost sharing allowed• States can go higher• Includes comprehensive dental


CHIP for Children:1997 Provisions

“Medicaid Light”

States were given the options of:

1. Expanding Medicaid

2. Mimicking Medicaid

3. Creating a novel new program

• Covers children birth through18 years• Targets children from 100-200% poverty, States can go higher• State entitlement• Paid by states and federal government (larger federal share than

Medicaid EPSDT)• Income-related copayments or cost sharing allowed• Dental was optional and varied widely (unless Medicaid was

expanded or mimicked)


FL EPSDT and CHIP Programs

Modified from Jill Boylston Herndon 2009

Poor

Near Poor

Working Poor

Not Poor

0-100% FPL 100-133% FPL 133-185% FPL 185-200% FPL 200% + FPL Ages 6-18

Healthy Kids (Novel CHIP) HK Self Pay 5 Year Olds

Medicaid For Children (EPSDT)

Preschoolers

Medi Kids (CHIP/EPSDT Look-Alike) MK Self Pay

Infants


CHIP for Children:New in 2009 for Medicaid and CHIP

Migrating to Prevention1. At birth ECC counseling for all2. Mandatory reporting on numbers of children with new sealants

Parental Assistance3. Mandatory beneficiary information4. InsureKidsNow help finding a participating dentist

Program Improvements5. Mandatory performance reporting 6. MACPAC: Medicaid and CHIP Payment and Access Commission7. Quality Assurance reporting requirement

8. Congressional study of • Dentists “willingness” to care for the underserved• New midlevels• Medicaid network adequacy• Providers for CSHCN• Geographic availability of dentists


Healthcare Reform(Health Insurance Reform)


FL Coverage Conclusions

The good news:• FL’s socially vulnerable children have excellent

insurance coverage.• FL’s coverage includes comprehensive dental services.

The bad news:• FL’s coverage does not translate into care except for 1-

in-5 covered children.• FL’s system is complex with different components

having different networks and administrators.


“ While several factors contribute to the low use of dental services among low-income persons who have coverage, the major factor is difficulty finding dentists to treat them.” (GAO)

Why Coverage Doesn’t Translate Into Care:

Inadequate Funding of Care


Access or Utilization?


Parents did well reporting on their children’s oral health status.

How well did they do on reporting dental visits?

Children’s Use of Dental Services:FL Children in Medicaid

Dental Visit in Last Year by Age

0

10

20

30

40

50

60

70

80

90

2–4 5–14 15–24 25–34 35-44 45-54 55-64 65-74 75-84 85+

Age

% w

ith

Den

tal

Vis

it

NHANES III MEPS 2000 NHIS 2001 Medicaid

All people tend to over-report (recall bias) so validation is important.


Fixes


1. Disease management fixes:Bio-behavioral interventions

1. Community collaboration: WA ABCD Program

2. Disease management: DentaQuest ECC QI project

3. Parent engagement: Motivational interviewing

4. Pharmacologic therapies: Fluoride, Xylitol, biofilm disruptors, remineralizers

5. Perinatal programs: AAPD/CDHP

6. Early diagnosis and medical management: industry

7. Primary care medical engagement: AAP


2. Access to care fixes: connecting children to care

Systems-think at community level:

7. Triage: IA virtual dental home

8. Care coordination: Tomkins County New York

9. Outreach: Adopt-a-______ programs (especially EHS) & establish dental homes

10. Mobile systems: UB regional system of care (from outreach to OR)

11. Medical-dental linkage: AmeriChoice NJ incentivized referrals

12. Public-private linkage: FQHC contracting

13. Community based services & better safety net: New Haven school based program


3. Workforce fixes: expand traditional supply

14. Expand functions: PA EFDAs EFHAs

15. Organize outreach to dentists: SDDD-SDDA collaboration

16. Empower dental practices: – by enhancing competencies in pediatric dentistry– by exploring cultural competency– by sharing experiences, frustrations, and ‘best practices’– by hearing from those who currently treat these kids– by learning more about these kids, their families, their lives– by meeting with Medicaid program officials

– by addressing business concerns that recast charity to profitability

17. Translate volunteerism into core services: GKAS, MOMs, DDS

18. Match a group of children to an office

19. Recognize & honor active providers


3. Workforce fixes: Systems-think – match need to care

General Dental Practices

Specialty Dental Practices

“Safety Net” Sites

Special Population Systems(Veterans Adm, Military, Prisons)

Special Care Systems(LTC, Domiciliary, Mobile)

Tertiary CareSystems

• More complex

• Smaller

• Less accessible

• More costly


Managed Practices

Private PracticesMobile Practices

Novel Practices

SafetyNets


Dr. Robert Grunstein’s GP for Children


3. Workforce fixes: new supply

20. Grow the pediatric dental specialty workforce: MD licensure for foreign grads trained in the US after fellowship in FQHC

21. Explore all new workforce models:– Dental therapists:

• AK Dental Health Aide Therapist

• MN Basic and Advanced Therapists

• Canadian model

– Dental hygienist-therapists: International model: Great Britain, The Netherlands, Australia, New Zealand

– Community dental health coordinators: ADA Proposal

– Advanced Dental Hygiene Practitioner: ADHA Proposal

22. Engage disease managers: CDE model from Behavioral Nutrition, Social Work, Health Education, Public Health, Environmental Health

-- Pediatric Oral Health Educator (analog to the Certified Diabetes Educator)

23. Partner with Medicaid-only general practices: FORBA, Kool Smiles


4. Medicaid program fixesFinancial

24. Structural reform: VA “ASO Single Vendor Non-Risk Carve Out”– Payment

– Paperwork

– Care coordination

– Advisory Council

– Data tracking & analysis

25. Payment reform: Payment at market rates (MA, CT, DE, SC …)

26. Financial incentives:– Higher payment rates for young children (RI)

– Volume incentives (UT)

– Training incentives (WA)

– HIT Incentives (ARRA)

– Capitalization incentives (HRSA)

27. Pay for Performance (P4P)


4. Medicaid program fixesAdministrative

30. Disease management benefit

31. Mandatory pregnancy coverage: CA, LA

32. Enhanced coverage of adults with special needs

33. Mandatory coverage of adult basic services (at least relief of pain and infection)

34. Updated periodicity schedule: FL Age one dental

35. Contracting: Explicit authorization by Medicaid

36. Enrolment: Outreach and enroll more eligible beneficiaries


Going Forward:Starting with Your Questions!

children’s dental health project medicaid, chip, & healthcare reform: options and...

Documents

world of childrens oral

childrens oral status

dental services

reform health insurance

dental repair

adolescent health website

care slide

mouth slide