children’s dental health project medicaid, chip, & healthcare reform: options and...
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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
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
The Mouth
Children’s Dental Health Project www.cdhp.org
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?
Children’s Dental Health Project www.cdhp.org
The Issue:Oral Health & Dental Care of FL Children
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
FL Children’s Oral Health Status:Parent Assessment by Age
But how well does parent assessment fit with clinical examination?
Children’s Dental Health Project www.cdhp.org
FL Parents Do Very Well Assessing Their Children’s Oral Status
Children’s Dental Health Project www.cdhp.org
Yet Problems Remain (Regardless of who you ask)
Children’s Dental Health Project www.cdhp.org
And they matter
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
– 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
Children’s Dental Health Project www.cdhp.org
So Who Has Poor Oral Health in FL?Oral Health by Income
1-in-6 Poor children;5 x more
than Affluent children
Children’s Dental Health Project www.cdhp.org
So Who Has Poor Oral Health in FL?Oral Health by Race/Ethnicity
1-in-8 Hispanic children
4x greater; than white children
Children’s Dental Health Project www.cdhp.org
So Who Has Poor Oral Health in FL?Oral Health by Insurance
1-in-10 Medicaid children;
2x Privately Insured Children
Children’s Dental Health Project www.cdhp.org
So Who Has Poor Oral Health in FL?Oral Health by Consistency of Insurance
1-in-8 “gap” children;
2x children with
Consistent Coverage
Children’s Dental Health Project www.cdhp.org
So Who Has Poor Oral Health in FL?Oral Health by Family Structure
1-in-6 Mom-only children;
4x Two Parent children
Children’s Dental Health Project www.cdhp.org
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
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So Who Has Poor Oral Health in FL?Oral Health by Severity of Special Needs
1-in-4 CSHCN;4x Children
without special needs
Children’s Dental Health Project www.cdhp.org
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)
Children’s Dental Health Project www.cdhp.org
Psycho-Social
Biological
Beha-vioral
Environ-mental
Genetic
Sources of Health & Health Disparities
Children’s Dental Health Project www.cdhp.org
Newacheck 2006Fisher Owens 2007
Sources of Health and Disparities
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Rethinking the Players:Roles for All!
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Potential Interventions
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Dental Care of Florida Children
Children’s Dental Health Project www.cdhp.org
Most underserved are young children of low income minority families whose parents have little education
Dental Care: US Picture
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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
Children’s Dental Health Project www.cdhp.org
YES VISIT NO VISIT
Children’s Use of Dental Services:FL Young children
More than half of young children have no dental visit
Children’s Dental Health Project www.cdhp.org
YES VISIT NO VISIT
Children’s Use of Dental Services:FL Multiracial children
Racial-ethnic minority children have fewer visits
Children’s Dental Health Project www.cdhp.org
YES VISIT NO VISIT
Children’s Use of Dental Services:FL Spanish language children
Spanish speaking children have fewer visits
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Children’s Use of Dental Services:FL Poor children
YES NO
Half of poor children have no visits
Children’s Dental Health Project www.cdhp.org
Children’s Use of Dental Services:FL Children in Medicaid
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
Does lack of access explain poorer health status for vulnerable children?
Determinants of health status
Children’s Dental Health Project www.cdhp.org
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?
Children’s Dental Health Project www.cdhp.org
The Opportunities:Options Provided by Congress
Children’s Dental Health Project www.cdhp.org
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”
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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)
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
Healthcare Reform(Health Insurance Reform)
Children’s Dental Health Project www.cdhp.org
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.
Children’s Dental Health Project www.cdhp.org
“ 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
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Access or Utilization?
Children’s Dental Health Project www.cdhp.org
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.
Children’s Dental Health Project www.cdhp.org
Fixes
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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
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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
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Managed Practices
Private PracticesMobile Practices
Novel Practices
SafetyNets
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Dr. Robert Grunstein’s GP for Children
Children’s Dental Health Project www.cdhp.org
Children’s Dental Health Project www.cdhp.org
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
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)
Children’s Dental Health Project www.cdhp.org
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
Children’s Dental Health Project www.cdhp.org
Going Forward:Starting with Your Questions!
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