Delivery and Financing of Dental Services in the Safety Net: an Overview

Andrew SnyderPolicy SpecialistNational Academy for State Health PolicyJune 24, 2008

The Big Picture

Dental disease is the most prevalent chronic disease of childhood

Low-income populations bear the burden of oral disease disproportionately

Many barriers to accessing care– Low dentist participation in public programs– No dental in Medicare– Transportation, time off, translation

What I’ll discuss

Recent UDS data on dental service delivery and staffing at health centers

Funding streams: Medicaid and coverage expansions through state health care reform

Utilization

UDS Dental Encounters, 1996-2006

59.22

32.92

6.152.73

10.4%8.3%

0

10

20

30

40

50

60

70

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

En

cou

nte

rs (

mil

lio

ns)

Total Encounters

% Dental Encounters

Dental Encounters

UDS Dental Users, 1996-200615.03

8.10

2.56

1.14

14.1%

17.0%

0

2

4

6

8

10

12

14

16

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Use

rs (

mil

lio

ns)

Total Users

Dental Users

% Dental Users

UDS Grantees Providing Dental Services On-Site, 2002-2006

58%

60%

62%

64%

66%

68%

70%

72%

74%

76%

2002 2003 2004 2005 2006

Preventive

Restorative

Emergency

Workforce

UDS Dental FTEs, 2000-2006

0

500

1000

1500

2000

2500

3000

3500

4000

2000 2001 2002 2003 2004 2005 2006

Allied Staff

Dentists

Hygienists

Source: Roger Rosenblatt, Holly Andrilla, Thomas Curtin, and Gary Hart. “Shortage of Medical Personnel at Community Health Centers,” Journal of the American Medical Association 295, No. 9 (2006): 1042-10491.

Dentist Vacancy Rates at Health Centers (2004)

Source: American Dental Association, Survey Center. US Census Bureau (2001).

Active Dentists per 100,000 Population (2000)

Dental HPSAs

Supply, Redistribution Strategies

Loan repayment– National Health Service Corps, state programs– Often linked to service in HPSAs or CHCs

Licensing strategies – Foreign dentists in safety net settings– Licensure by credential– Licensure after service, residency

Increased use of non-dentists– “Public health” settings, “hub and spoke” arrangements– Using physicians, nurses to screen, educate, provide preventive

measures

Financing

Medical and Dental Uninsurance

Public26%

None16%

Private58%

Private53%

Public12%

None35%

Medical Insurance, 2006(Source: www.statehealthfacts.org)

Dental Insurance, 2004(Source: MEPS Chartbook 17)

Medicaid38%

Medicare6%

Other Public2%

Private Third Party7%

Indigent Care Programs

3%

Other Revenue2%

BPHC Grants20% Other Federal

Grants2%

State and Local Grants

9%

Private Grants4%

Patient Self-Pay7%

Overall Health Center Revenue, 2006

Dental services are less than 2% of Medicaid spending

2%15%

16%

67%

Dental Benefits

Nursing Home Care

Prescription DrugBenefits

Other Services

*Centers for Medicare and Medicaid Services. MSIS State Summary, FY 2004: Table 17, FY 2004 Medicaid Medical Vendor Payments by Service Category (CMS, June 2007).

Dental services are 5% of national health care expenditures

5%7%

12%

76%

Dental Services

Nursing Home Care

Presciption Drugs

Other Services

**Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group. National Health Expenditure Accounts: Total Personal Health Care Spending, By Age Group, Calendar Years 1987, 1996, 1999, 2002, 2004 (Baltimore, MD: U.S. Department of Health and Human Services, 2004).

States with Full Medicaid Dental Benefits for Adults

14

12

8 8

7

9

0

2

4

6

8

10

12

14

Nu

mb

er

of

Sta

tes

2000 2002 2003 2004 2005 2006

Year

States with Emergency or No Benefits for Adults in Medicaid

20

2527

26 26

22

0

5

10

15

20

25

30

Nu

mb

er

of

Sta

tes

2000 2002 2003 2004 2005 2006

Year

Status of Health Care Reform

“Universal” plans under way: Maine, Massachusetts, Vermont

Pieces of plan in action: Illinois, Washington, Pennsylvania, Wisconsin, Kansas

Being debated in legislatures: New Mexico, Connecticut, California

Commissions: Colorado, Minnesota, New York, Oregon

Status of Health Care Reform

2008 has seen slowdown in the rate of progress– Financial and housing crises– Deteriorating state budgets– Stalled SCHIP reauthorization– CMS interpretations of federal matching rules

under Medicaid and SCHIP, especially for children over 250% FPL

Dental Care in Reform Could Mean…

Setting up structure so people can purchase benefits

Expansion of structures like SEHP, FEDVIP, or Medicaid

Providing benefits to priority populations Paying attention to safety net, prevention,

integration with medical care, to lower costs down the line.

...But So Far, It Has Meant:

No systematic addressing of dental uninsurance

Dental benefits in Medicaid and CHIP expansions for kids

Limited expansions for specific adults– Pregnant women, some parents

Some investment in dental workforce, prevention

Massachusetts

Reform established new independent public authority called “the Connector” which designs coverage and works with businesses, insurance companies, providers and consumers.

Dental benefits are provided in MassHealth (Medicaid) and Commonwealth Care for all adults with income <100% FPL, and parents up to 133% FPL.

Children up to 300% FPL continue to receive comprehensive oral health benefits.

Funds added to “Health Safety Net Trust Fund” for safety net clinics to provide dental services for those without dental coverage between 100-300% FPL.

Maine

State’s subsidized insurance plan – DirigoChoice – was implemented in January 2005.

Focus on: chronic disease, the Maine Quality Forum (promoting quality and education), voluntary limits on growth of premiums, and electronic claims.

Sliding scale for premiums and out-of-pocket expenses based on family income.

Dental benefits only in MaineCare: comprehensive for under age 21, but only emergency/dentures for adults.

Oral health improvement plan developed by the state was released in November 2007.

– 13 goals around data, workforce, prevention, changing attitudes

Vermont

Catamount Health created in May 2006 - provides subsidized coverage through private insurers for families up to 300% FPL.

One plan (MVP) offers limited preventive and diagnostic coverage for kids under 19.

Oral health will be addressed in reforms of chronic care management and care coordination programs.

“Dental Dozen” – 12 targeted initiatives planned to improve oral health for all Vermonters.

– Outreach, loan repayment, missed appointment reporting, involvement of physicians

– Raised Medicaid reimbursement rates

Illinois

“All Kids” program opens the state’s Medicaid program to all uninsured children, with Medicaid dental benefit, administered by Doral

Efforts to introduce “Illinois Covered” expanded coverage for adults ran into legislative problems– Private “Choice” product included optional buy-in

to dental insurance

Colorado

Recommendations of blue-ribbon commission would provide CHP+ dental benefit to new enrollees, with $1000 annual cap, including adults

Recommended loosening restrictions on dental hygienists’ ability to practice to full extent of their scope

Wisconsin

“BadgerCare Plus” introduced in 2007 to expand health coverage to all uninsured children, and most uninsured adults

“BC+ Benchmark Plan” modeled after commercial medical coverage, includes limited dental coverage for higher-income children and pregnant women

– Coverage for diagnostic, preventive, and some restorative services

– $200 deductible, 50% coinsurance, $750 maximum annual benefit

Kansas

Expanded Medicaid coverage of routine dental services (including cleanings, restorative, perio) to pregnant women under 200% FPL

Legislature previously approved $500,000 for development of health center “dental hubs”

Conclusion

Dental service delivery through CHCs is growing, and an important part of many states’ strategies– Dental uninsurance more prevalent than medical

uninsurance, – Medicaid is under-funded, and adult coverage is

spotty

Conclusion

CHC dental workforce is growing, but small, faces structural, geographic challenges– CHCs can serve as laboratories for new

workforce approaches, integration with medical care

Even though many states are opting not to address dental in health care reform, there are some positive moves afoot

Contact

Andrew SnyderPolicy SpecialistNational Academy for State Health Policy1233 20th Street, Suite 303Washington, DC 20036

asnyder@nashp.org(202) 903-0101http://www.nashp.org