WITHOUT CHANGE IT’S THE SAME OLD DRILL

Improving Access to Denti-Cal Servicesfor California Children Through

Private Dentist Participation

Presented at the

UCSF Dental Public Health SeminarJanuary 29, 2013

2

The Study

Study Team:

Barbara Aved, RN, PhD, MBA Principal Investigator BAA President

Ron Inge, DDS, Vice President Delta Dental, Washington

Larry S. Meyers, PhD BAA Research Associate

Funders:

LIBERTY Dental Plan Health Net

Purpose: Examined:

Challenges in the CA Medicaid (Medi-Cal) Dental fee-for-service (FFS) program

Extent of private practice DDS participation in the program

Factors that account for DDS willingness to accept patients with Denti-Cal in their practices

Looked at: Access, utilization, quality

Project Period:

May 2012 – October 2012

Primary Study Questions

Who is serving the Medi-Cal population and at what levels?

What are the main reasons for unwillingness of private practice dental practices to take or restrict the number of children with Medi-Cal, and what would it take to increase their likelihood of participating?

To what extent do children with Medi-Cal utilize the ED for dental conditions considered preventable?

How do practices that accept Medi-Cal successfully offset any negative aspects of the program?

What is the FFS complaint/grievance system for families when they experience access or quality problems, how many use it (on their own and with help from advocates), and with what results?

What performance requirements are there for FFS providers concerning quality and cost containment?

Background

45% of CA children ages 0-17 are covered by public insurance, primarily Medi-Cal.

23,318 DDSs in active practice in CA in 2008.

In 2008, ~24% of CA private practice DDSs accepted Medi-Cal (down from 40% in 2003).

Of the DDSs with at least 1 paid Medi-Cal claim in 2008, only 33% had paid claims of >$10,000.

Medi-Cal Dental is primarily FFS (managed care only in 2 counties); CA dropped general adult coverage in 2009.

CA has one of the lowest Medicaid dental reimbursement levels in the U.S.

5

Methods

Review of past, related studies

Confer with Medi-Cal Dental staff (CA Department of Health Care Services)

Secondary data collection (mostly from DHCS, 2011)

Claims data from rendering providers (i.e., encounters/procedures); comparison data from child-only commercial dental plan

Utilization data Pt. grievances (filed with State; contacts to advocacy

organizations) Emergency dept. use

Interviews (key informants—policymakers, advocates, dental experts)

Methods, Cont.

DDS Survey (local General and Pediatric DDSs)

Developed detailed survey (review by DHCS, CDA)

5-County Sample Local dental society

involvement (~80% DDSs are members)

Mailing lists for paper version + Cover Letter

Hosted survey on website for online response

~ 2,000 surveys mailed

$10 Starbucks gift card as incentive

Rationale for Sample SelectionUrban/mostly urban county where Medi-Cal dental is the FFS system.

Validation of a utilization problem (ages 0-20 utilization rates lower than statewide average).

Very few community clinics with dental services.

Demographics that generally mirror the CA population.

Willingness of local organizations to be supportive of the study.

7

Methods (cont.)

Study Limitations:

Focus on urban areas (where majority of Medi-Cal pop. lives)

DDS survey based on sample pop. (not statewide)

Paid claims level info not available (DHCS wouldn’t provide it)

Dental services provided in community clinics not included in analysis (they have their own reimbursement model)

8

Key Findings

UtilizationUtilization of Medi-Cal FFS Dental Services, Children Ages 0-20, 2011

Source: Department of Health Care Services, Medi-Cal Dental Services Division, August 2, 2012.Children continuously enrolled in FFS for at least 11 months during Calendar Year 2011.

California lags behind 39 other states re. proportion of children receiving any dental services, and 37 other states of those receiving preventive dental services under the EPSDT dental benefit.

Age 0-3 Age 4-5 Age 0-20

31.1% 66.4% 52.2%

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Utilization Findings (cont.)

Main Reasons Parents Reported for No Dental Visit

Source: 2009 California Health Interview Survey, UCLA

Reason

No reason to go/no perceived problem

34.7%

Child perceived as not old enough

25.0%

No insurance/can’t afford dental care

16.0%

Other 24.3%

ED Findings

In 2010, CA children ages 0-18 made 19,766 ED visits due to one of the 10 primary diagnoses of an oral condition;

Two-thirds (13,282) of these considered preventable. 51.3% of the ED visits were made by children ages 0-

5. Percent of Children’s ED Visits for Oral Conditions Considered

Preventable, 2010

73.3%60.8% 67.2%

0%

20%

40%

60%

80%

100%

Ages 0-5 Ages 6-18 Ages 0-18

(n=7,435) (n=5,847) (n=13,282)

ED Findings (cont.)

Percent of Preventable ED Visits by Payer Source, Ages 0-18, 2011

Percent of ED Visits with Public Payer Source, Ages 0-18, 2007 2011

Public Prog, 61.5%

Priv Insur, 27.0%

Self Pay, 11.5%

61.5%60.0%

58.7%

55.5%55.0%

50%

52%

54%

56%

58%

60%

62%

2007 2008 2009 2010 2011

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DDS Survey Findings

Study Sample N=322 (16.2% response rate) Online responses = 14.6% of total surveys. Proportion received from general (83.3%) and

pediatric (16.7%) DDSs generally equivalent to proportion of surveys sent to each group.

Proportion sent to each county representative of surveys mailed.

Business and personal characteristics mostly matches CA dentist profile (see next slide)

Characteristics General Practice Pediatric Practice

Total Number of Survey Respondents 276 46

Number of Years in Practice n % n %

1 - 10 years 54 20.7% 20 46.5%

11 - 20 years 71 27.2% 11 25.6%

21 or more years 136 52.1% 12 27.9%

Size of Practice n % n %

Solo 175 66.3% 26 60.5%

Small Group 75 28.4% 15 34.9%

Large Group/Clinic 14 5.3% 2 4.7%

Gender n % n %

Female 89 34.2% 19 41.3%

Male 171 65.8% 27 58.7%

Race/Ethnicity n % n %

African American 4 1.5% 3 6.7%

Asian/Pacific Islander 93 35.6% 24 53.3%

American Indian 3 1.1% - -

Hispanic 15 5.7% 2 4.4%

White, non-Hispanic 127 48.7% 13 28.9%

Other 19 7.3% 3 6.7%

DDS Survey Findings, cont.

DDS Survey Findings, cont.

Age When Child is First Seen (all DDS survey respondents) 58% of general DDSs start seeing children at age 3 or older

0102030405060708090

100

1 2 3 4 5 6

Age of Child

Perc

en

tag

e

General Practice Pediatric Practice

DDS Survey Findings, cont.

Participation in Medi-Cal FFS Dental Program (called “Denti-Cal”)

Total sample: 26.8% General DDS: 24.8% Ped DDS: 37.0%

Those who accept M-C see a low volume 38% of general DDSs had 15% or fewer M-C kids in their

practice. 56.3% ped DDS had <5% M-C in their practice

Provider satisfaction level

42.9%

9.0%

25.4%34.3% 31.3%28.6% 28.6%

0.0%0%

15%

30%

45%

60%

Satisfied SomewhatSatisfied

SomewhatUnsatisfied

Unsatisfied

General DDS (n=67)

Pediatric DDS (n=14)

DDS Survey Findings, cont.Reasons for Not Accepting Medi-Cal by Rankings

All Dentists (N = 168)

Most Importan

t

1

2 3 4 5 6 7 8 9LeastImport

ant

10

Patient follow-through/compliance with recommendations and referrals (n = 92)

612

921

36

4 2 1 1 -

Broken appointments (n = 116)

1125

23

38

13

6 - - - -

Complex paperwork/administrative requirements (n = 116)

2123

44

20

6 1 - 1 - -

Difficulty getting payment (back and forth with claims issues) (n = 116)

1851

21

11

14

- - - 1 -

Reimbursement rate (n = 163)

10622

25

2 6 1 - - - 1

Dentist is willing; staff is not willing to take Denti-Cal (n = 39)

2 - 2 - - 714

7 7 -

Staff is willing; dentist is not willing to take Denti-Cal (n = 38)

- 1 - 2 110

10

12

2 -

Language issues (i.e., not being able to communicate effectively) (n = 50)

- 2 1 5 215

812

5 -

Competition with larger offices or clinics hurt us (n = 43)

1 - 1 1 3 5 6 421

1

Other (n = 16) 3 - 1 4 - 1 2 - - 5

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DDS Survey Findings (cont.)

Typical wait times for M-C appointments:

<2 weeks for a no-problen appt 2-3 week wait for a treatment visit (reported by 50%

of ped DDSs)

Most of the 24.8% who accept M-C report they do so without restriction.

90% of general DDSs said it was “very difficult” or “somewhat difficult” to find a ped dentist for M-C problem referrals.

DDS Survey Findings (cont.)

The characteristics of DDSs less likely to accept M-C are:*

In practice for more than 20 years

In solo practice

Male

White, non-Hispanic

*Statistically significant (chi square analysis)

FactorDid Factor Influence DDS Acceptance of

Medi-Cal?

Years in Practice

1 to 10 years Did not matter (not statistically significant)

11 to 20 years Did not matter (not statistically significant)

21 or more years Less likely to accept

Size of Practice

Solo Less likely to accept

Small Group More likely to accept

Large Group More likely to accept

Gender

Female More likely to accept

Male Less likely to accept

Race/Ethnicity

Asian/Pacific Islander More likely to accept

White, non-Hispanic Less likely to accept

DDS Survey Findings (cont.)

A small proportion of general DDSs reported they have the interest/capacity to see more kids with Medi-Cal.

Characteristics of General Practices Wanting to See More Medi-Cal Children with the Capacity to do so

20%

38%43% 43%

40%

18%

53%48%

40%

33%

0%

15%

30%

45%

60%

75%

1-10years

11-20years

21+ years Solo Small Large Female Male AsianPacificIslander

White(non-

Hispanic)

Claims (Procedures) Data Findings

The number of participating DDSs has been declining over the last 5 years (table).

Ratio of general DDS access points to eligible children of 1:178 is w/in industry standards. From there, however, ratios vary significantly

for pediatric and other dental specialties.

Ratios camouflage important issue of provider distribution and access within CA counties, particularly for specialty care.

Eligible Children Rendering Providers

FY 2008-09 1,687,852 9,100

FY 2009-10 1,924,129 8,786

CY 2011 2,585,137 7,878Source: Medi-Cal Dental Services Division.

Ratio of Eligibles to DDS Points of Access

Eligibles GP PED OS ENDO ORTH PERIO PROS

2,585,137 178 4,981 152,067 123,102 1,271 80,786 80,786

Source: Medi-Cal Dental Services Division.

Claims (Procedures) Findings, cont.

82% participating in M-C served <100 new children with M-C in 2011.

Service category concerns (anomalies with certain categories of claims):

High frequency of restorative and endodontic services may indicate a lack of preventative services for children.

Claims for dental sealants—a proven strategy to prevent decay—not submitted in expected numbers given that kids with M-C are at higher risk for decay than kids in the general population.

High submissions of claims for extractions suggest the children’s teeth were unsalvageable at the time of the visit.

Claims (Procedures) Data Findings, cont.

Similar submissions by payers – Diagnostic-Oral Exams; Preventive; Restorations.

Dissimilar submissions by payers (significant differences) – Diagnostic-Radiographs/ Diagnostic Imaging; Endodontics; Periodontics.

Contribution of Categories of Care to the Total Number of Claims submissions for Medi-Cal

Compared with Commercially Insured Child Population.

17.0%

36.0%

0.7%

5.1%

12.0%

21.0%

14.0%

0.0%

2.0%

2.0%

3.4%

0.6%

3.6%

1.0%

1.0%

16.5%

17.0%

21.0%

11.0%

2.0%

0.0%

3.7%

0% 10% 20% 30% 40%

Diagnos - Exams

Diagnos - Imaging

Prevention

Restor - Direct

Restor - Indirect

Endo

Perio

Prosth

Oral & Maxillo

Ortho

Adj Dental

Children with Denti-Cal (n=10,069,987) Commerically Insured Children (n=11,397)

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Lessons from Other States

Implementing strategies that increase access and utilization:

Increase in provider rates Targeted provider recruitment Reduction of the administrative burden associated

with Medicaid (e.g., streamline enrollment) Outreach to beneficiaries regarding how to best

access and utilize services Education of parents to better understand the

importance of preventive services Education of providers

Recommendations

1. Make Medi-Cal more attractive to encourage participation. Streamline and expedite the dental provider enrollment process.

2. Simplify claims submission to reduce provider burden and lower costs.

3. Raise Medi-Cal dental FFS rates.

4. Recruit more dentists into the Medi-Cal dental program by targeting those most likely to enroll.

5. Adopt more quality measures for the FFS program.

6. Monitor Medi-Cal dental utilization rates, provider participation and providers-to-eligibles ratios.

7. Monitor Medi-Cal dental claims for patterns linked to over utilization and patient safety.

8. Sponsor more trainings for general DDSs to increase their comfort and skill level in seeing younger children.

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Recommendations (cont.)

9. Expand outreach and education to families on the availability and importance of early, regular dental care for children.

10. Make Medi-Cal dental data more easily accessible and in more usable formats for studies like this one.

11. Collect EPSDT dental data from federally funded clinics that allow more accurate reporting of utilization rates.

12. Support the collection of more recent and consistent CHIS (California Health Information Survey) data on oral health.

13. Identify a “legislative champion(s)” willing to be visible in taking on an oral health leadership role.

14. Examine more closely the reasons why more parents do not fully utilize Medi-Cal dental benefits for their children.

15. Outreach to women whose pregnancies are covered by Medi-Cal to educate women about the importance of getting a dental visit for themselves and their children.

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Thank you!

Questions?

Full report available at:

www.barbaraavedassociates.com