Oral Health: Strategies to Improve AccessOral Health: Strategies to Improve Access

Washington, DC

Oral Health SessionNovember 14, 2008

2008 Fall NASMD Meeting

Mary G. McIntyre, M.D., M.P.H. Medical Director, Office of Clinical Standards and QualityAlabama Medicaid Agency

What’s The Problem?What’s The Problem?

• Tooth decay is the most common chronic

childhood disease, five times more common than

asthma.

• 80 percent of pediatric dental disease is

concentrated in 25 percent of children, primarily

those from low-income and minority households.

• Adults lose 164 million work hours per year

because of dental problems.

State of AlabamaState of Alabama

•Population of 4.7 million

•67 counties / 45 non-MSA

•Medicaid eligibles 988,678+

•State/Federal match of about 30/70

• In Alabama, about 20% of population is Medicaid eligible

•About 47% of all Medicaid eligible children are from working families

•Population of 4.7 million

•67 counties / 45 non-MSA

•Medicaid eligibles 988,678+

•State/Federal match of about 30/70

• In Alabama, about 20% of population is Medicaid eligible

•About 47% of all Medicaid eligible children are from working families

Demographics

Medicaid covers:

20% of Alabama’s total population (includes all eligibility categories)50% of all deliveries in Alabama38.9% of Alabama’s children (under 19)21.2% of Alabama’s elderly (65 and above)

Source: 2006 Annual Report

Alabama Medicaid Dental ProgramAlabama Medicaid Dental Program

Vision StatementDental Program

Vision StatementDental Program

To ensure every child in Alabama enjoys optimal health by providing equal and timely access to quality, comprehensive oral health care, where prevention is emphasized promoting the total well-being of the child

To ensure every child in Alabama enjoys optimal health by providing equal and timely access to quality, comprehensive oral health care, where prevention is emphasized promoting the total well-being of the child

Smile Alabama! InitiativeSmile Alabama! Initiative

•Public/Private Partnership

•Robert Wood Johnson Foundation’s 21st Century Challenge Fund supported matching grants program

•Dental Outreach Initiative-Official Start, February 2001

•Public/Private Partnership

•Robert Wood Johnson Foundation’s 21st Century Challenge Fund supported matching grants program

•Dental Outreach Initiative-Official Start, February 2001

GoalsGoals

•Increase the number of dental providers participating in the Medicaid program by 15% during the 3-year grant period

•Increase the number of children receiving dental care by at least 5% (Annual Dental Visit Rate)

•Increase the number of dental providers participating in the Medicaid program by 15% during the 3-year grant period

•Increase the number of children receiving dental care by at least 5% (Annual Dental Visit Rate)

PremisePremise

Good oral health prevents pain, suffering, missed days of school or work and unnecessary costs due to

dental treatment.

Good oral health prevents pain, suffering, missed days of school or work and unnecessary costs due to

dental treatment.

Why Is Good Oral Health Important?

Why Is Good Oral Health Important?

• Dental related illness causes poor children to “miss” 12 times more school days than children from higher income families

• Poor oral health has been associated with other medical problems including heart disease and premature births

• Dental related illness causes poor children to “miss” 12 times more school days than children from higher income families

• Poor oral health has been associated with other medical problems including heart disease and premature births

Where We Started…Where We Started…

• Identification of Key Individuals who could make the difference...

Dentists (ALDA)

AL Medicaid Agency

AL Department of Public Health

Governor

Legislature

Dental School

• Identification of Key Individuals who could make the difference...

Dentists (ALDA)

AL Medicaid Agency

AL Department of Public Health

Governor

Legislature

Dental School

We Listened…We Listened…

• Formation of Dental Task Force

Non-Medicaid and Medicaid dentists

Alabama Dept of PH and UAB School of Dentistry

Dental Task Force discussed Medicaid issues

Dental Surveys done

#1 Issue - Low Reimbursement

#2 and #3 – Claims Processing

• Formation of Dental Task Force

Non-Medicaid and Medicaid dentists

Alabama Dept of PH and UAB School of Dentistry

Dental Task Force discussed Medicaid issues

Dental Surveys done

#1 Issue - Low Reimbursement

#2 and #3 – Claims Processing

Timeline…

Formed Dental Task Force Jan 1998 Targeted Rate Increase Jan 1999

Coordinate with State Dental Association

Survey of state dentists 1999 and 2000

Develop educational materials for dentists

Provider enrollment User friendly billing manual Aug/Sept 1999

Streamline claims payment Oct

1999 ADA approved claim forms Scanning technology Free software for electronic claims

submission (Windows Based)

Proclamation April 2000 Educate legislature

Enlist Governor’s Support Spring 2000

Governor’s Letter to Dentists Oct 2000

Timeline…

Timeline…

Establish Multidisciplinary Workgroup

Evaluate state needs for all

March 2000

Outreach program Provider visits July/Aug 1999

Visit all participating dentists March 2000 Attend state and regional meetings Ongoing Speak to dental students yearly Ongoing Dental Outreach Specialists June 2001- 2004

Timeline…

Grant applications RWJ April & Nov 2000

NGA Oct 2000

Targeted Case Management (TCM) March 2000

Increase in Fees Oct 2000 Developed patient education materials

May 2001-Ongoing

Public education campaign Nov 2001, April 2003

Video and Public Service Announcements (TV &

Radio)

Working Together…Working Together…

• Establishment of Additional Teams

Dental Initiative Workgroup evolved into

current Oral Health Coalition of Alabama

(OHCA)-Initial focus on AL Medicaid oral

health strategies, now work to implement

strategies for AL OH Strategic Plan

AL NGA Policy Academy Team now AL

Oral Health Strategic Team (AOHST)

• Establishment of Additional Teams

Dental Initiative Workgroup evolved into

current Oral Health Coalition of Alabama

(OHCA)-Initial focus on AL Medicaid oral

health strategies, now work to implement

strategies for AL OH Strategic Plan

AL NGA Policy Academy Team now AL

Oral Health Strategic Team (AOHST)

Oral Health Policy Team (NGA)Oral Health Policy Team (NGA)

• Alabama Dental Association

• Alabama Department of Public Health

• Alabama Medicaid Agency

• Alabama Primary Health Care Association

• Child Health Insurance Program

• CMS Regional Office

• Governor’s Office

• Legislator

• Office of Primary Care & Rural Health

• Private dentist

• UAB Dental School

• Alabama Dental Association

• Alabama Department of Public Health

• Alabama Medicaid Agency

• Alabama Primary Health Care Association

• Child Health Insurance Program

• CMS Regional Office

• Governor’s Office

• Legislator

• Office of Primary Care & Rural Health

• Private dentist

• UAB Dental School

Oral Health Coalition of Alabama (OHCA)

Oral Health Coalition of Alabama (OHCA)

• Alabama Office of the Governor

• Alabama Legislature

• Alabama Extension Service

• Alabama Medicaid Agency

• Alabama Department of Public Health

• Department of Rehabilitation Services

• Department of Children’s Affairs

• Department of Education

• Department of Human Resources

• Department of Mental Health

• UAB School of Dentistry

• Alabama Office of the Governor

• Alabama Legislature

• Alabama Extension Service

• Alabama Medicaid Agency

• Alabama Department of Public Health

• Department of Rehabilitation Services

• Department of Children’s Affairs

• Department of Education

• Department of Human Resources

• Department of Mental Health

• UAB School of Dentistry

Oral Health Coalition of Alabama (OHCA)

Oral Health Coalition of Alabama (OHCA)

• Alabama Academy of Family Physicians

• Alabama Academy of Pediatrics

• Alabama Arise

• Alabama Association of School Nurses

• Alabama Hygienists Association

• Alabama Dental Association

• Alabama Dental Society

• Alabama Hospital Association

• Alabama Pediatric Dental Association

• Alabama Primary Health Care Association

• Alabama Academy of Family Physicians

• Alabama Academy of Pediatrics

• Alabama Arise

• Alabama Association of School Nurses

• Alabama Hygienists Association

• Alabama Dental Association

• Alabama Dental Society

• Alabama Hospital Association

• Alabama Pediatric Dental Association

• Alabama Primary Health Care Association

OHCA (Continued)OHCA (Continued)

• Alabama State Medical Association

• Alabama Power

• Business Council of Alabama

• Blue Cross and Blue Shield of Alabama

• Consumer Representatives

• Faith Based Organization

• FOCAL

• Head Start

• Medical Association of the State of Alabama

• Medicaid Dental Task Force

• VOICES

• Alabama State Medical Association

• Alabama Power

• Business Council of Alabama

• Blue Cross and Blue Shield of Alabama

• Consumer Representatives

• Faith Based Organization

• FOCAL

• Head Start

• Medical Association of the State of Alabama

• Medicaid Dental Task Force

• VOICES

Target Populations IdentifiedTarget Populations Identified

•Medicaid children and caregivers

•Practicing dentists

•Stakeholder or partner associations and groups

•Medicaid children and caregivers

•Practicing dentists

•Stakeholder or partner associations and groups

InterventionsInterventions

•Claims Processing Simplification

•Dental Rate Increase

•Provider Outreach and Education

•Consumer and Patient Education

•Claims Processing Simplification

•Dental Rate Increase

•Provider Outreach and Education

•Consumer and Patient Education

Educational ToolsEducational Tools

• Healthy teeth, healthy mouth, healthy you!– Head Start OH Lesson Plans (Initially with most recent use by

Office of School Readiness for Pre-K programs

• Take a 1st Look

– Primary Care Physician (focus on OH risk assessment and referral by age 3)

– Revised 1st Look (Effective Jan 2009, added fluoride varnishing reimbursement for 1st Look certified physicians and requirement for referral to care coordinator for establishment of dental home for all high risk children assessed through 1st Look, ages 6 through 35 months of age)

• Obstetrical Early Intervention– Pregnant women (Taking Care of Baby’s Teeth)

• Healthy teeth, healthy mouth, healthy you!– Head Start OH Lesson Plans (Initially with most recent use by

Office of School Readiness for Pre-K programs

• Take a 1st Look

– Primary Care Physician (focus on OH risk assessment and referral by age 3)

– Revised 1st Look (Effective Jan 2009, added fluoride varnishing reimbursement for 1st Look certified physicians and requirement for referral to care coordinator for establishment of dental home for all high risk children assessed through 1st Look, ages 6 through 35 months of age)

• Obstetrical Early Intervention– Pregnant women (Taking Care of Baby’s Teeth)

I’ll have water, please!

Going to bed with a bottle of milk or juice can cause a problem called baby

bottle tooth decay.

A tooth with decay can cause great pain and can cost a lot of money to fix.

To prevent this problem•Put water in nap or bedtime bottles.

• Don’t let baby carry around a bottle or sippy cup filled with a sweet drink.

• Don’t dip pacifiers in anything sweet.

• By the first birthday,teach your baby to drink from a cup.

•Clean baby’s mouth with a clean, damp cloth after each feeding and before bed.

Having healthy teeth is an important part of your good health. Medicaid’s dental program is set up to help you get good dental care. In order for you to get good dental care, there should be respect and trust between you and your dentist.

When you signed up for Medicaid, you agreed to be a part of Medicaid and to follow Medicaid’s rules. This also means you have the following rights and duties when you go for dental care on the Medicaid program:

You have the right:• To be told what your dental problem is, if you have one,

and what the dentist thinks is the best way to treat it;• To decide about your dental care and to give your

permission before the start of any treatment;• To have the personal information in your dental records

kept private;• To report to Medicaid any complaint or grievance about

your doctor or your medical care; and• To be treated with respect, dignity and privacy.

Your Rights and Duties As a Dental PatientRead this and find out what you need to know!

You need to know . . .Your dentist has the right to ask you to follow the rules for the office or clinic. This also applies to any visitors or relatives who come with you or your child. If you or others with you do not follow the rules, your doctor has the right to ask that your child go to another dentist.

Serious problems, such as refusing to keep appointments, or acting in a rude, mean or threatening way to the dentist or to a person who works for the dentist, may result in your losing your Medicaid. This includes fighting, using profanity or other abusive words, carrying a weapon or being under the influence of drugs or alcohol while at the office or clinic.

To be signed by the patient:

I have been told about my rights and duties as a Medicaid dental patient. I have been told what the rules are for my dentist’s office or clinic. I have been given the chance to ask questions about any rules I do not understand.I have been told that if I miss appointments, do not follow the dentist’s directions or do not follow the rules for Medicaid, my dentist can ask that my child go to another dentist.

I understand that if I or someone who comes with me acts in a rude, mean or threatening way to the dentist, employees of the office or clinic and/or other patients and visitors, I can lose my Medicaid.

I have been told that I have a right to complain to Medicaid and get an answer to my complaint.

Signed: ___________________________ Date: _____________________________

Baseline DataBaseline Data

• In FY 1999, 82,585 of 317,214 Medicaid eligible children received dental services (26%)

•436 Medicaid enrolled dentists

•Of these, 328 were participating (75.2%)

•Total dental expenditure of $11.6

•19 counties had 1 or no Medicaid participating dentist

• In FY 1999, 82,585 of 317,214 Medicaid eligible children received dental services (26%)

•436 Medicaid enrolled dentists

•Of these, 328 were participating (75.2%)

•Total dental expenditure of $11.6

•19 counties had 1 or no Medicaid participating dentist

Where We Are NowWhere We Are Now

•FY 2007, 187,613 of 460,525 Medicaid eligible children received dental services (41%)

•778 Medicaid enrolled dentists for FY 07

•Of these, 748 participating (96%)

•Total dental expenditures of $54 million

•6 counties with 1 or no Medicaid participating dentist as of February 2008 (there were no counties with ‘no Medicaid participating dentist’)

•FY 2007, 187,613 of 460,525 Medicaid eligible children received dental services (41%)

•778 Medicaid enrolled dentists for FY 07

•Of these, 748 participating (96%)

•Total dental expenditures of $54 million

•6 counties with 1 or no Medicaid participating dentist as of February 2008 (there were no counties with ‘no Medicaid participating dentist’)

FY1998-FY2007FY1998-FY2007

RESULTSRESULTS

Figure 1. Alabama Dental Medicaid Utilization, 1998-2007

Figure 1. Alabama Dental Medicaid Utilization, 1998-2007

0

5

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15

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35

40

45

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

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Figure 3. Performing Dentists, Alabama Dental Medicaid, 1998-2007

Figure 3. Performing Dentists, Alabama Dental Medicaid, 1998-2007

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Performing DDS Saw 100+ Patients Billed $10,000+

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Performing DDS Saw 100+ Patients Billed $10,000+

Figure 2. Enrolled and Performing Dentists, Alabama Dental Medicaid, 1998-2007

Figure 2. Enrolled and Performing Dentists, Alabama Dental Medicaid, 1998-2007

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Enrolled providers Performing providers

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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Enrolled providers Performing providers

Figure 4. Percent Medicaid Eligibles Receiving Any Dental Service, by age category, U.S. and Alabama, FY 2006

Figure 4. Percent Medicaid Eligibles Receiving Any Dental Service, by age category, U.S. and Alabama, FY 2006

0.6

13

40

4844

38

21

34

14

5153

48

38

6

37

0.30

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50

60

age < 1 age 1-2 age 3-5 age6-9 age 10-14 age 15-18 age 19-20 all ages

Age

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U.S. Alabama

0.6

13

40

4844

38

21

34

14

5153

48

38

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37

0.30

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age < 1 age 1-2 age 3-5 age6-9 age 10-14 age 15-18 age 19-20 all ages

Age

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on

U.S. Alabama

Figure 4. Percent Medicaid Eligibles Receiving Any Dental Service, by age category, U.S. and Alabama, FY 2006

Figure 4. Percent Medicaid Eligibles Receiving Any Dental Service, by age category, U.S. and Alabama, FY 2006

What Can You Do?What Can You Do?

• Assist in the distribution of information to increase knowledge on the importance of good oral health to overall health

• Support funding for Medicaid and ALL-Kids

• Encourage dentists to participate in serving low-income children

• Assist in the distribution of information to increase knowledge on the importance of good oral health to overall health

• Support funding for Medicaid and ALL-Kids

• Encourage dentists to participate in serving low-income children

“If you always do,

What you always did,

You always get,

What you always got.”

Jackie “Moms” Mabley

“If you always do,

What you always did,

You always get,

What you always got.”

Jackie “Moms” Mabley