[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
NECESSARY REFORM TO PEDIATRIC DENTAL CARE UNDER MEDICAID
=======================================================================
HEARING
before the
SUBCOMMITTEE ON DOMESTIC POLICY
of the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 23, 2008
__________
Serial No. 110-190
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
EDOLPHUS TOWNS, New York TOM DAVIS, Virginia
PAUL E. KANJORSKI, Pennsylvania DAN BURTON, Indiana
CAROLYN B. MALONEY, New York CHRISTOPHER SHAYS, Connecticut
ELIJAH E. CUMMINGS, Maryland JOHN M. McHUGH, New York
DENNIS J. KUCINICH, Ohio JOHN L. MICA, Florida
DANNY K. DAVIS, Illinois MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts TODD RUSSELL PLATTS, Pennsylvania
WM. LACY CLAY, Missouri CHRIS CANNON, Utah
DIANE E. WATSON, California JOHN J. DUNCAN, Jr., Tennessee
STEPHEN F. LYNCH, Massachusetts MICHAEL R. TURNER, Ohio
BRIAN HIGGINS, New York DARRELL E. ISSA, California
JOHN A. YARMUTH, Kentucky KENNY MARCHANT, Texas
BRUCE L. BRALEY, Iowa LYNN A. WESTMORELAND, Georgia
ELEANOR HOLMES NORTON, District of PATRICK T. McHENRY, North Carolina
Columbia VIRGINIA FOXX, North Carolina
BETTY McCOLLUM, Minnesota BRIAN P. BILBRAY, California
JIM COOPER, Tennessee BILL SALI, Idaho
CHRIS VAN HOLLEN, Maryland JIM JORDAN, Ohio
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
JACKIE SPEIER, California
Phil Barnett, Staff Director
Earley Green, Chief Clerk
Lawrence Halloran, Minority Staff Director
Subcommittee on Domestic Policy
DENNIS J. KUCINICH, Ohio, Chairman
ELIJAH E. CUMMINGS, Maryland DARRELL E. ISSA, California
DIANE E. WATSON, California DAN BURTON, Indiana
CHRISTOPHER S. MURPHY, Connecticut CHRISTOPHER SHAYS, Connecticut
DANNY K. DAVIS, Illinois JOHN L. MICA, Florida
JOHN F. TIERNEY, Massachusetts MARK E. SOUDER, Indiana
BRIAN HIGGINS, New York CHRIS CANNON, Utah
BRUCE L. BRALEY, Iowa BRIAN P. BILBRAY, California
JACKIE SPEIER, California
Jaron R. Bourke, Staff Director
C O N T E N T S
----------
Page
Hearing held on September 23, 2008............................... 1
Statement of:
Kuhn, Herb, Acting Director, Center for Medicaid and State
Operations; and Alicia Cackley, Acting Director, Health
Care Team, Government Accountability Office................ 36
Cackley, Alicia.......................................... 50
Kuhn, Herb............................................... 36
Tucker, Susan, MBA, executive director, Office of Health
Services, Maryland Department of Health and Mental Hygiene;
Patrick Finnerty, director, Virginia Department of Medical
Assistance Services; Mark Casey, DDS, MPH, medical
director, North Carolina Division of Medical Assistance;
Linda Smith Lowe, esq., public policy advocate, Georgia
Legal Services Program; Jane Grover, American Dental
Association; and Jim Crall, director, Oral Health Policy
Center, professor and Chair, Section of Pediatric
Dentistry, UCLA School of Dentistry........................ 86
Casey, Mark.............................................. 112
Crall, Jim............................................... 174
Finnerty, Patrick........................................ 95
Grover, Jane............................................. 143
Lowe, Linda Smith........................................ 124
Tucker, Susan............................................ 86
Letters, statements, etc., submitted for the record by:
Cackley, Alicia, Acting Director, Health Care Team,
Government Accountability Office, prepared statement of.... 52
Casey, Mark, DDS, MPH, medical director, North Carolina
Division of Medical Assistance, prepared statement of...... 115
Crall, Jim, director, Oral Health Policy Center, professor
and Chair, Section of Pediatric Dentistry, UCLA School of
Dentistry, prepared statement of........................... 178
Finnerty, Patrick, director, Virginia Department of Medical
Assistance Services, prepared statement of................. 98
Grover, Jane, American Dental Association, prepared statement
of......................................................... 145
Kucinich, Hon. Dennis J., a Representative in Congress from
the State of Ohio:
Prepared statement of.................................... 5
Prepared statement of Burton Edelstein................... 197
Kuhn, Herb, Acting Director, Center for Medicaid and State
Operations, prepared statement of.......................... 38
Lowe, Linda Smith, esq., public policy advocate, Georgia
Legal Services Program, prepared statement of.............. 126
Tucker, Susan, MBA, executive director, Office of Health
Services, Maryland Department of Health and Mental Hygiene,
prepared statement of...................................... 89
NECESSARY REFORM TO PEDIATRIC DENTAL CARE UNDER MEDICAID
----------
TUESDAY, SEPTEMBER 23, 2008
House of Representatives,
Subcommittee on Domestic Policy,
Committee on Oversight and Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 a.m. in
room 2154, Rayburn House Office Building, Hon. Dennis J.
Kucinich (chairman of the subcommittee) presiding.
Present: Representatives Kucinich, Cummings, Higgins, and
Issa.
Also present: Representative Higgins.
Staff present: Jaron R. Bourke, staff director; Noura
Erakat, counsel; Jean Gosa, clerk; Charisma Williams, staff
assistant; Leneal Scott, information systems manager; Jill
Schmalz, minority counsel; Molly Boyl, minority professional
staff member; and Larry Brady, minority senior investigator and
policy advisor.
Mr. Kucinich. We have just been informed that the ranking
member is en route and he urges us to start, so we will.
The subcommittee will come to order.
This is the Domestic Policy Subcommittee of the Oversight
and Government Reform Committee. Today is Tuesday, September
23, 2008. The hearing today is entitled, ``Necessary Reform to
Pediatric Dental Care under Medicaid.''
Today's hearing is going to examine the progress of reform
in Medicaid's pediatric dental entitlement.
Without objection, the Chair and the ranking minority
member will have 5 minutes to make opening statements, followed
by opening statements not to exceed 3 minutes by any other
Member who seeks recognition.
Without objection, Members and witnesses may have five
legislative days to submit an opening statement or extraneous
materials for the record.
Nearly a year and a half ago a 12-year-old boy named
Deamonte Driver died of a brain infection caused by untreated
tooth decay. Deamonte lived in Prince George's County, MD, and
was a Medicaid beneficiary, and as such was en titled to dental
care paid by the American taxpayers. But he hadn't seen a
dentist for more than 4 years.
Since then my subcommittee began an investigation into the
adequacy of pediatric dental care under Medicaid. In May 2007
my subcommittee held a hearing to determine the circumstances
that led to Deamonte's preventable death. Nine months later we
examined what corrective actions the Center for Medicaid and
State Operations, CMS, had taken since Deamonte's death to
reform the dental program for Medicaid-eligible children.
Today we seek to move beyond identifying problems with our
pediatric dental program under Medicaid and start identifying
the reforms necessary to fix a broken system. Moreover, we will
have the opportunity to recognize Federal and State officials
who have taken the lead in fixing this system by implementing
some of those reforms.
After our May hearing, I instructed our subcommittee staff
to investigate the adequacy of the dental provider network
available to Medicaid-eligible children enrolled in the same
managed care company that was responsible for Deamonte. My
subcommittee investigated United Healthcare's dental network
and records of claims submitted for services rendered to United
beneficiary children in 2006.
What my staff found was appalling. Deamonte was far from
the only child in Maryland who hadn't seen a dentist in 4 or
more consecutive years. In fact, nearly 11,000 Maryland
children enrolled in United had not seen a dentist in 4 or more
consecutive years, putting them in the same precarious position
that Deamonte was in at the time of his death.
The investigation also revealed that United Health Care's
dental provider network was not nearly as robust as they
claimed. We discovered that only seven dentists provided 55
percent of all dental services rendered in 2000 in the county
where Deamonte resided.
Shortly after the release of our investigatory findings in
October 2007 I instructed my subcommittee staff to expand its
investigation into three managed care organizations in addition
to United in three other States and counties. The survey, the
results of which are made available to the Center on Medicaid
and State Operations by letter last week, assessed United and
Health Care Choice in Apache County, AZ; United and Amerigroup
in Essex County, NJ; United and Keystone Mercy in Philadelphia
County, PA; and Amerigroup in Prince George's County, MD.
I ask unanimous consent to enter my letter into the record.
The finding of this expanded investigation reveals that
inadequate dental provider networks and poor utilization rates
are not limited to any single MCO or to any single
jurisdiction. The problems are system-wide.
Our survey revealed that many, many thousands of children
enrolled in Medicaid are not receiving dental care for up to 6
consecutive years. We have a chart up that is supposed to
represent that. I don't know if anybody is going to be able to
read it. I certainly can't from here. But this slide indicates
how many children did not see a dentist in 4 or more
consecutive years.
The percentage of children enrolled in Medicaid without
dental services for 4 consecutive years between 2003 and 2006
ranged between 25 and 31 percent across all States and MCOs.
But percentages are one thing and numbers are another. This
means that in Philadelphia County, for example, 34,947 children
enrolled in Keystone Mercy did not see a dentist between 2003
and 2006. These are children who are entitled to this care.
Are any of those children suffering from untreated tooth
decay? If so, will it be caught before it leads to another
tragic story?
Our survey also revealed that dental provider networks are
as woefully inadequate in these other jurisdictions and MCOs
are as they were in Prince George's County in 2006.
In all jurisdictions among all MCOs examined, only between
two and nine dentists performed half of all services rendered
to children enrolled in Medicaid in fiscal year 2006. This is
in Prince George's County.
United's provider network in Essex County, NJ, boasts of
203 dentists. At first glance, it appears that parents in Essex
County can easily access a dentist to treat their child. But
look a little closer and you will find that only 9 dentists of
the 203 enrolled in United's provider network provided 50
percent of all services to children enrolled in the MCO.
Why are large numbers of dentists enrolled in a managed
care organization's network but not providing care? What will
it take to change their status from inactive to active
providers of dental care for Medicaid-eligible children?
We began to explore answers to this question earlier this
year. In February this subcommittee held a hearing to evaluate
CMS's reforms in pediatric dental care under Medicaid since the
death of Deamonte. The hearing revealed the inadequacy of the
agency's reforms, prompting this subcommittee to press CMS to
do more to achieve greater access to and utilization of
pediatric dental care. My subcommittee made six policy
recommendations to CMS in this vein.
I ask for unanimous consent to enter my letter into the
record.
Since that time, CMS has come under new leadership. Today
we will hear from CMS and learn that the agency has taken great
strides in responding to these recommendations. CMS's
accomplishments since our last hearing mark a significant and
positive shift in its approach to providing dental care for our
country's poorest children.
We will also hear from representatives of several State
Medicaid agencies whose programs provide instructive lessons
for other States struggling to improve their pediatric dental
program under Medicaid. We will hear about the positive impact
of increasing reimbursement rates in Maryland, about the
positive impact of a disease management model in North
Carolina, and about the positive impact of creating a single
vendor administrator for dental care in Virginia.
The history of pediatric dentistry under Medicaid is deeply
disturbing. The system of Government and private managed care
companies that was entrusted by the American people to take
care of children like Deamonte Driver has been in a shambles.
According to the Government Accountability Office's most recent
report on oral health, not much has changed over the past two
and a half decades. GAO's report is the first of its kind since
2000, when the Surgeon General released a report on oral health
in the United States and found that low-income children
suffered twice as much from tooth decay than more affluent
children.
But our hearing today is going to show that over the past
year and a half, through congressional oversight, the tireless
work of advocates, and the dedication of State and Federal
officials, lessons have been learned since Deamonte's death.
Initiatives have been undertaken, and a Federal agency, long
accustomed to a laissez-faire attitude toward Medicaid has
finally awakened.
I look forward to hearing the testimony from our witnesses
and believe it will demonstrate to the American people that
reform has come to Medicaid and society can be guardedly
optimistic.
Thank you.
[The prepared statement of Hon. Dennis J. Kucinich and the
information referred to follow:]
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Mr. Kucinich. At this time I recognize the ranking member,
who has worked with us throughout this entire matter, Mr. Issa
of California. Thank you, sir, for being here.
Mr. Issa. Thank you, Mr. Chairman.
Mr. Chairman, this is the fourth in a series of hearings.
Unlike some of the hearings that often occur, not just in this
committee but in other committees, where you have a hearing,
you play ``gotcha,'' and then you move on, you have steadfastly
stood to try to not only bring awareness to this problem, but,
in fact, to go beyond that to bring and oversee changes.
These hearings were, of course, first prompted by the
tragic death and avoidable death of Deamonte Driver, who died
of a brain infection as a result of tooth decay.
Mr. Chairman, I appreciate your efforts to prevent any
event like this from happening in the future. It is very clear
that, of all the areas of medical coverage that America does
the least well, it is dentistry, not because we don't have the
finest dentists or the finest dentistry in the world--we do, we
lead the world--but programs such as Medicaid, which often talk
in terms of preventative activities, certainly do a fine job on
vaccines, but they fail to hit the most important part of the
responsibility. Poor oral health is a leading cause of so many
other diseases and, of course, leads to a lifelong inability to
be healthy and to regain that health.
Mr. Chairman, the fact that you have made it your mission
to go after failures of Medicaid and CMS, failures to oversee
the States who have the primary responsibility--as we both
know, dentistry is not an entitlement, but where, in fact,
States have agreed to do it, the Federal Government is a full
partner in that. We need to make sure that is being delivered
properly.
As you said in your opening statement, it is very, very
clear that just having a program is not of any value if you
have no access because of an insufficient number of dentists
available. Dentists react to the market faster than any other
part of medicine. Dentists will immediately recognize if we are
not paying a sufficient amount or not authorizing services for
those they need. Dentists are, in fact, small businessmen, for
the most part, and, unlike physicians, they can't rely on a
hospital or other offsets.
A dentist who is particularly pediatric and operates in a
poor area or under-served area is going to find himself with
patients who can't pay that he is trying to finance, patients
who seek Medicaid, and a relatively small amount of patients
who have full dental coverage.
Mr. Chairman, your work has prompted the GAO report being
released today, which will be discussed in the first panel, but
which, in fact, is an opportunity for you and I together and
others in Congress to take this challenge, which has not yet
been met, into the next Congress.
I look forward to the briefing here today.
I also would like to thank you for the invitation you
placed to the American Dental Association. You and I both know
that Government has often failed to go to those who have the
expertise and say, why is it we are failing? Why is it that
dentists often choose not to take Medicaid patients? Today we
are going to have an opportunity to see and hear what is still
wrong, what has been improved, and, equally importantly, to
talk to the professionals who we have to make future programs,
both at the Federal and State level and particularly Medicaid,
fit their needs or we will not have full access to coverage.
Mr. Chairman, often one person gives their life and becomes
a poster child for people to complain about the system. In this
case you have done a great job, and I would like to commend you
as we near the end of Congress, for using that tragic loss to
bringing about permanent and profound change.
I look forward to, for the rest of this Congress and into
the next Congress, working with you on a bipartisan basis to
find solutions that work for the children who today are not
getting the dental care that will lead to a healthy adult life.
I yield back and thank the chairman for his leadership.
Mr. Kucinich. I want to thank the ranking member. For those
of you who may not be aware of it, Mr. Issa and I both hail
from Cleveland, although I am privileged to represent it in the
Congress. Mr. Issa and I both understand from our childhood
experiences the relevance of this pediatric dental issue. When
you know that personally, you understand and become very
involved in a way that can be constructive.
So I want to say that the progress that we have been able
to have here could not have happened without your participation
and your support, because when you have a committee work and
something gets done, it is not just one person that brings it
about; you have to have a partner on it. Mr. Issa has been a
terrific partner on these things, so I want to thank you as we
move forward.
I also want to recognize our staff of the subcommittee,
because without it we wouldn't be able to get into the depth
that we have been able to get into. There is still a long way
to go, but we have had some progress.
Let's start by introducing the first panel.
Mr. Herb Kuhn is the acting director of the Center for
Medicaid and State Operations. He is a nationally recognized
expert on value-based purchasing and payment policy. Mr. Kuhn
most recently served as director for the Center of Medicaid
Management. As CMM director, Mr. Kuhn oversaw the development
of regulations and reimbursement policies for the fee-for-
service portion of Medicare, covering the universe of providers
that care for 43 million elderly and disabled Americans under
Medicare.
Ms. Alicia Puente Cackley is an Acting Director at the U.S.
Government Accountability Office. She currently directs several
teams of analysts doing health policy research, including
studies of Medicaid services for children and adults, and
immigrant detainee health. Prior to joining the health care
team, Ms. Cackley worked in GAO's education work force and
income security team, where she managed teams analyzing Social
Security reform, retirement and aging issues, as well as work
force immigration issues.
I want to thank you both for appearing before our
subcommittee today.
It is the policy of the Committee on Oversight and
Government Reform to swear in all witnesses before they
testify. I would ask that you rise and raise your right hands.
[Witnesses sworn.]
Mr. Kucinich. Let the record show that the witnesses have
answered in the affirmative.
I would ask each of the witnesses to now give a brief
summary of their testimony, and to keep the summary under 5
minutes in duration. Bear in mind your complete written
statement will be included in the hearing record.
I want to thank Mr. Higgins from New York for joining us.
Mr. Kuhn, let's begin with you.
STATEMENTS OF HERB KUHN, ACTING DIRECTOR, CENTER FOR MEDICAID
AND STATE OPERATIONS; AND ALICIA CACKLEY, ACTING DIRECTOR,
HEALTH CARE TEAM, GOVERNMENT ACCOUNTABILITY OFFICE
STATEMENT OF HERB KUHN
Mr. Kuhn. Good morning, Chairman Kucinich and members of
the subcommittee. Thank you for inviting me to discuss
pediatric dental care under Medicaid.
CMS shares this subcommittee's conviction that we must
improve dental care services for children with Medicaid. As I
have personally shared with Chairman Kucinich, our agency is
grateful for this subcommittee's leadership in this area. You
have provided us with helpful information as we move forward on
our efforts to improve care. In this regard, I wanted to take
my time today to give you an update on where we are with our
investigations and improvement efforts.
First, CMS has completed its onsite reviews of 17 State
dental programs. The States targeted for review were those
States where less than 30 percent of the children on Medicaid
were seen by a dentist in the previous year. CMS used 2006 as
the benchmark year. When these reviews are completed, we plan
to host a national town hall meeting to discuss our findings
and ask for suggestions on policy options to improve the
utilization of dental care for these vulnerable children.
Once we complete the national town hall meeting, we plan to
share our report through a State Medicaid director's letter to
all States and the District of Columbia. We intend to complete
this entire process by the end of this year.
I want to assure the committee that we are not waiting to
take actions with States on issues that are identified,
however, during these reviews. Once each State review is
completed, we are making a set of recommendations for each
State and are initiating compliance actions on those
recommendations.
Second, CMS has asked all States to update and submit to us
their dental periodicity schedules for review. As part of our
review, we have found that some States were out of compliance
with CMS requirements. Even more unfortunate, some States have
still not responded to our request for these oral health
schedules. Some of those States are represented by members on
this subcommittee.
We have shared with you the list of States that still have
not provided us with these oral health schedules. As part of
our ongoing partnership with this subcommittee on the Medicaid
dental program, I would appreciate your assistance in
contacting your own State to help us obtain those schedules.
Third, in collaboration with the National Association of
State Medicaid Directors, we have developed an oral health
technical advisory group. They helped us update the policy
questions and answers that you had inquired about, as well as
helping us with improvements in the annual EPSDT reporting
form. We all know we need to capture better data on dental
services, and we are hopeful that by improving this reporting
form it will help us identify areas of weaknesses on which we
can focus our attention.
We also are including dental activities in our State
quality assessment reports, and we are working with the
American Dental Association to create a dental quality alliance
to help us develop evidence-based performance measures.
Fourth, we have moved forward with the States on sharing
best practices, convening a national call to discuss innovative
State programs. I am excited about the growing collaborations
that we are seeing in various events, including the National
Oral Health Conference.
Finally, I would like to share with the subcommittee that,
since assuming the role as Acting Director of the Center for
Medicaid and State Operations, I have met with State Medicaid
Directors and discussed this issue at length. Furthermore, CMS
staff have been in contact with every State, from State
Medicaid directors to State dental officers to discuss these
issues. I can assure you that every State understands the
additional scrutiny we are putting them under.
While our work is far from done, I am confident that we are
moving in the right direction and look forward to continuing to
work with this subcommittee and others on improved pediatric
dental care.
I would be happy to answer your questions.
[The prepared statement of Mr. Kuhn follows:]
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Mr. Kucinich. I thank the gentleman.
The gentlelady may proceed.
STATEMENT OF ALICIA CACKLEY
Ms. Cackley. Mr. Chairman, Ranking Member Issa, members of
the subcommittee, I am pleased to be with you today as you
examine reform to pediatric care and Medicaid. This is an issue
this committee has been focused on for some time, since the
tragic death of Deamonte Driver.
My comments this morning are based on a report we prepared
for the subcommittee, which you are releasing today, entitled,
``Medicaid: Extensive Dental Disease in Children Has Not
Decreased, and Millions Are Estimated to Have Untreated Tooth
Decay.''
My remarks will cover three key questions that you asked us
to investigate: the extent to which children in Medicaid
experience dental disease, the extent of dental care they
receive, and how these conditions have changed over time.
In summary, dental disease and inadequate receipt of dental
care remains a significant problem for children in Medicaid
across the country. Our analysis of national data indicates
that approximately one in three children on Medicaid age 2
through 18 had untreated tooth decay, and 1 in 9 had untreated
decay in more than three teeth.
Projecting these percentages on 2005 Medicaid enrollment
levels, we estimate that 6.5 million children in Medicaid have
had untreated tooth decay. This rate of dental disease for
children in Medicaid was nearly double the rate for children
who had private insurance, and very similar to the rate of
children who are uninsured.
Turning to national data on receipt of dental care, we
found that nearly two in three children in Medicaid had not
received any dental care. Again, projecting these percentages
on 2005 enrollment levels, we estimate that 12.6 million
children in Medicaid didn't see a dentist in the previous year.
In addition, the data show that only about one in eight
children ever see a dentist.
As you may know, HHS has national health goals known as
Healthy People 2010, which include the target of having two-
thirds of low-income children receive a preventive dental
service in a given year. Our analysis shows that as a nation we
are way behind, since we found that only one-third of children
in Medicaid received any dental care in the previous year.
Looking over time, there is some good news to share with
you. Comparisons of past and more recent survey data suggest
that indicators of receipt of dental care, including the
proportion of children who had received dental care in the past
year and the proportion who had received dental sealants have
shown some improvements over time. The percentage of children
in Medicaid who received dental care in the previous year
increased from 31 to 37 percent over approximately 10 years.
In addition, the percentage of slightly older children,
whose aged 6 through 18 with at least one dental sealant
increased nearly three-fold.
Despite these improvements, however, we found that rates of
untreated tooth decay for children and Medicaid were largely
unchanged. We look at data around two time periods around the
early 1990's and compared it to the early 2000's. The
proportion of children in Medicaid who experienced tooth decay,
both treated and untreated, actually increased from 56 percent
to 62 percent over this time period.
In conclusion, the information provided by these national
surveys regarding the oral health of our Nation's children on
Medicaid raises serious concerns. Measures of access for dental
care for this population remained far below our national health
goals.
Of even greater concern are data showing that dental
disease is prevalent among children on Medicaid and is not
decreasing over time. Millions of children on Medicaid are
estimated to have dental disease and be treated. In many cases,
this need is urgent.
Given these conditions, it is important for all those
involved in providing dental care to children in Medicaid, the
Federal Government, States, providers, and others, to continue
working to improve the oral health condition of these children
and achieve stated national oral health goals.
I am not making specific recommendations today, but expect
to have more information for you once we have completed our
ongoing work for this subcommittee. This work includes
reviewing both State Medicaid programs ad CMS's efforts to
monitor and ensure the children in Medicaid receive recommended
dental services.
Mr. Chairman, this concludes my prepared statement. I would
be happy to respond to questions.
[The prepared statement of Ms. Cackley follows:]
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Mr. Kucinich. Thank you very much, Ms. Cackley. I would
like to start with you.
Why is the oral health condition in children with Medicaid
not improving if receipt of dental care has improved?
Ms. Cackley. That is a very good question. It seems
counter-intuitive. I think part of the explanation in part can
come from looking at the age differences in the children. When
we look at tooth decay in younger children, we see a much
larger increase, and that seems to be driving the overall trend
that we see, whereas older children, who are the ones most
likely to receive dental sealants, have no change, no increase
in tooth decay over time.
Mr. Kucinich. Well, in your testimony you say that children
from birth to three are not among the population of children
who are receiving greater treatment in the past 26 years.
Please elaborate on this finding. Also, what policies would you
recommend to Federal and State agencies to address lack of care
for the youngest sector of children in our Nation.
Ms. Cackley. The youngest children, in part, what we found
was that younger children did not receive dental sealants, and
partly that is it is not recommended for very young children.
Dental sealants are for permanent teeth and not for the
children who still have their primary teeth.
We don't have recommendations of specific policies at this
point, partly because we are still doing the work on looking at
what State Medicaid programs and their dental programs do have
in place, and I think our ongoing work will be able to give you
more recommendations at a later time.
Mr. Kucinich. Can you elaborate on how the condition of
dental disease in Medicaid children compared to children with
private health insurance and children without any insurance?
Ms. Cackley. Absolutely. The children in Medicaid had much
higher rates of tooth decay than children with private
insurance, and over time we actually saw children with private
insurance having lower rates of tooth decay, whereas children
on Medicaid had higher rates, and uninsured children, basically
their rates remained unchanged.
Mr. Kucinich. So why do you think that is? Why do you think
that children who have Medicaid have a higher rate of tooth
decay? They have the coverage, right, but they are not getting
the service? Is that it?
Ms. Cackley. That is correct. They definitely have
coverage. There are a number of reasons why they are not
getting services. In previous work that we have done, we looked
at the participants in our surveys who responded also to why
they did not have access to dental care, and in many cases they
responded that there were either cost issues or access issues
in terms of ability to find a dentist or ability to travel to
the dentist, so there are a number of different responses that
were given as to what the problem could be.
Mr. Kucinich. So in your model for further research, you
are going to take into account the distance between providers
and people who are clients?
Ms. Cackley. Our ongoing work is looking more particularly
at the State Medicaid programs and what they are doing, the
initiatives that they are putting in place to improve access to
care, which could include improving transportation or just
increasing the provider network so that people don't have to go
so far in order to find a dentist who will treat them.
Mr. Kucinich. If you see in some provider networks that a
few dentists are seeing half the patients, how do you explain
that?
Ms. Cackley. There are a number of reasons. In our previous
work we learned that dentists gave for why they were not
serving Medicaid children, and some of those included problems
with payments, but also problems with missed appointments and
administrative burden. Those are some of the reasons that we
had learned about.
Mr. Kucinich. Is there a point where GAO recommends that a
health care provider should not list someone in their list of
service providers if they are not willing to take Medicaid
patients? But why should someone be listed as a service
provider if they are not providing a service?
Ms. Cackley. I think that we will be looking very
specifically at the Medicaid State programs and how they go
about creating their network of providers and how they monitor,
how CMS monitors the provision of services so that we will be
able to tell you more about what the State regulations are on
that. We don't have information at this time.
Mr. Kucinich. Mr. Kuhn, the very nature of people who find
themselves on Medicaid, many of them are on the lower end of
the economic scale. Many of them have found themselves in
situations that have led to a certain amount of social
disorganization. Would you agree with that?
Mr. Kuhn. I would agree with that statement. Yes.
Mr. Kucinich. So if that is the case, what is the thinking
then of CMS, in looking at factors of social disorganization
with respect to the delivery of service? For example, if, as
Deamonte Driver's mother was faced with, you try and basically
this service isn't available, even though you are told, how are
people supposed to know how you keep proceeding? There is a
certain amount of skill in maneuvering the system, which is
required to be able to get this service.
We want to provide dental services for children, and we are
asking their parents to be able to be experts at maneuvering a
system that most people who aren't burdened with the kind of
problems that some of the poor may be burdened would have
trouble negotiating.
Transportation. You have a provider who might be on the
other side of a county. People may not have even traveled over
there before. There may not be adequate public transportation.
I mean, when you look at the lower rates of utilization, as
evidenced by the higher rates of tooth decay, it seems to me
that the old models of service providing that are based on a
society that has been a little bit less mobile than this one,
that has been perhaps a little bit more stable in terms of
economics than this one, that those old models are not as
reliable for the provision of service. And that,
notwithstanding the progress that you have made and are ready
to make, that it may be that, in order to continue to provide
services to a growing population of Medicaid clients, that you
may have to look at changing the way that you serve this
program population.
Mr. Kuhn.
Mr. Kuhn. Mr. Chairman, I would not only agree that we need
to look at those; I think we need to challenge some of those
old models. I think we are planning to challenge those in a
number of different ways. I think the issues that you and the
CBO have raised here in terms of the multi-factorial issues are
all relevant that we have to look at when serving this
population, and some of the challenges that we need to think
about is, how good are these provider networks, whether they
are MCOs or others, are reaching back out to the folks that are
enrolled in the program and making sure that they are doing the
appropriate followup, the proper education, the information
that they need.
I think you will hear about it from some of the innovations
that we are hearing from some of the States that are here today
in terms of really trying to capture the service of non-
dentists and others that are delivering care that can provide
care, because if you look at the data that certainly I have
seen and others, children on Medicaid and children overall tend
to see a primary care physician or someone else much more
frequently than they see a dentist. And in some cases and in
some States because of licensure they are able to deliver at
least some kind of services in those areas. Likewise with
hygienists and others.
So I think we need to challenge some of the models that are
out there and try to find better ways to do this.
I couldn't agree more.
Mr. Kucinich. I want to recognize that CMS, since our last
meeting in February and since your becoming Acting Director,
and indicated by your testimony, under leadership CMS has done
a much better job in addressing our policy recommendations.
Significantly, it has resuscitated the oral health tag and
enabled State dental agency leaders to collaborate with CMS and
one another to tackle oral health disease. I want to thank you
for that, and I hope that you will continue with your efforts
in new and innovative ways.
I have a few questions that I wanted to ask of you in light
of recent developments.
Before I do that, I want to recognize Mr. Higgins for the
purposes of asking some questions.
Mr. Higgins, you may proceed.
Mr. Higgins. Thank you very much, Mr. Chairman.
Just for context, Ms. Cackley, do all States provide
children's dental services under the Medicaid program?
Ms. Cackley. Yes, they do.
Mr. Higgins. All do? Obviously, some do it better than
others.
Ms. Cackley. Yes.
Mr. Higgins. What are the models that are particularly
effective that meet or exceed the benchmarks that were outlined
in your study?
Ms. Cackley. The study that I just testified on was looking
at the national data on receipt of dental services and
prevalence of dental disease. It is the ongoing work where we
will be able to talk about, across the State programs, what are
some of the exemplary programs and where there are some places
where we can make recommendations.
I don't have that information yet.
Mr. Higgins. Well, in assessing the problem, the period of
study was between 2004 and 2005?
Ms. Cackley. Yes.
Mr. Higgins. Obviously, there are some that are more
interesting and likely targets for further review based on the
quality of these programs. I presume that these statistics are
available on a State-by-State basis, as the Medicaid program is
both funded by the Federal and the State governments.
Ms. Cackley. The data that our study is based on are data
sets that are provided by HHS, the National Health and
Nutrition Examination and the Medical Expenditure Panel, so
they are aggregate data nationally representative.
Mr. Higgins. You are being too cautious with me.
Ms. Cackley. I am sorry?
Mr. Higgins. I am trying to understand this a little bit
better.
I mean, it would seem to me, at the request of Congress, if
you have identified in your report a public health issue that
addresses children in this Nation, and that the Medicaid
program, again, is funded by both the Federal and the State
governments, and in some States like New York by local
governments--25 percent, which comes from the property tax--it
would seem to me that a good place to start is within those
States that are doing well, and why is it that they are doing
better than everybody else, and then looking at that State or
those States collectively as a basis from which to perhaps
recommend to Congress specific recommendations as you
acknowledge that you are not doing here today.
Ms. Cackley. Right. You are absolutely right. What I am
trying to say is that what we have done so far is to look at
data that is not broken out State-by-State where the children
live, so we can't give you that kind of information yet. The
State-by-State kinds of information will come in the second
phase.
Mr. Higgins. I would think that information would be very
valuable.
Ms. Cackley. I am sure it will.
Mr. Higgins. Yes.
I have no further questions, Mr. Chairman. Thank you.
Mr. Kucinich. Thank you, Mr. Higgins.
Mr. Kuhn, you mentioned that you have finalized 4 of the 17
early periodic screening and diagnostic treatment reviews, and
that you have completed a draft of an additional seven of them.
Can you tell us what challenges that all these States have in
common?
Mr. Kuhn. That is a good question. You know, in our written
testimony on page 4 we list some of the initial observations
that we are making as a result of all of our reviews of the
States, and so when you look at it across the board what we are
seeing here is that one of the fundamental things is clear
information for beneficiaries, particularly those with
different languages, particularly some that are of different
cultures. Seems to be a barrier that we are seeing in all
States in all the 17 areas.
Also, we see deficiencies in many of the States in terms of
processes that would remind beneficiaries that recommended
visits were due that are out there.
Updated provider listings, everybody seems to be falling
down in terms of making sure those are current and adequate and
they are appropriate that are in place there.
A process to track when recommended visits ought to be
occurring seems to be a common theme we are seeing across the
States.
These are some of the commonalities that we are seeing
across the board.
Likewise, for providers we are seeing the same thing that I
think this subcommittee has heard in the past--low provider
payment rates, the issue of missed appointments that were
mentioned earlier, and also sometimes with prior
authorizations. Sometimes the dentists find those are
burdensome.
So we are seeing those kind of common themes across the
board.
Mr. Kucinich. Why have people missed appointments? Do you
ever go into deep detail about missed appointments? Are there
any patterns?
Mr. Kuhn. In one of the reviews I read in one of the States
it was interesting, I think it was North Dakota, where the
issue of missed appointments, the dental providers in that
State, when they book an appointment with a Medicaid
beneficiary, they double booked all those appointments because
they said there was a high likelihood that the patient might
not show up that day, and they didn't want an empty chair that
is there. So we see some work-arounds the providers are doing.
So as part of our reviews with these 17 States we have done
detailed discussions with the providers to try to understand
those kind of issues, what they are doing in order to
ameliorate that.
I think the issue of double booking is an interesting one.
It seems to me that if we were more effective at reminding
people of visits and appointments and doing some other things
we might be able to help work in that area, but these are some
of the things that we are seeing.
Mr. Kucinich. I want to go a little bit deeper into this
discussion about CMS and, for that matter, any Federal service
that is being provided, how service is being provided, other
than dental.
If you are dealing with a population that is suffering from
poverty and social disorganization, time, there is a different
awareness of time. Now, I am speaking about this because this
is basically how I grew up. Appointments don't mean the same
thing to some people as they mean to others. Once you are
working you are on a clock, there is a regimentation to life,
you are out with the rest of society, you are moving with the
crowd. Time, you are looking at a watch, means one thing. Some
people, life doesn't work that way.
It is the awareness of that which I think is important to
be able to deliver service, because in a way, when appointments
are made, I think the followup, calling people, asking the
providers to call people a day before an appointment, for
example, reminding them there is an appointment, the day of an
appointment reminding them there is an appointment, I mean,
there is something about that I would like you to think about
to take into account.
You know, this might sound a little bit like sociology, but
let me tell you there is a practical application to doing this.
There is also a practical application to outreach, to continual
outreach to make people aware of the provision of services to
maximize the use of the Medicaid dollar, itself.
I just would like your response to that, and then I want to
move on.
Mr. Kuhn. I think those are good questions to ask, and in
one regard I am very grateful that this particular hearing you
have asked experts from the individual States who are actually
on the ground grappling with those very issues as they
implement these programs, so I will be interested to hear what
they say.
But what we hear on our interviews is, in addition to the
issue of missed appointments, one of the things that they said
is absolutely right. People have work, and how does that
integrate with their work schedule. They have babysitter issues
that they have to deal with. They have transportation problems
and issues that come up. So all of those are kind of multi-
factorial things that I think we have to think about.
Are there different things that we could do at CMS to help
support the States in that regard or are there additional
innovations that States can bring forward to help these
Medicaid beneficiaries navigate the system with those kind of
issues and challenges that they face.
Mr. Kucinich. I appreciate that response. You indicated
that CMS targeted States reporting dental screening rates below
30 percent for focused dental reviews. However, a large number
of States reported screening rates in the 30 to 40 percent
range. What is CMS doing to improve access to Medicaid dental
services in States beyond the initial targeted 15 States?
Mr. Kuhn. Yes. What we have done in that regard, while we
did focus on those 17 States, we have been in contact with each
and every State to talk with them about the issues that are out
there. We talked to them about trying to understand better what
are the actions they are taking to followup with children, or
at least the provider networks are following up with children
to make sure that they are getting the services that they need
and, as you so rightly said, that they are entitled to and that
they deserve, to make sure that we are following up with each
and every State to get the periodicity schedules. We have
almost got those all done. We are still missing a few States.
As we have shared with the subcommittee, we have shared with
you the ones that are still missing and we hope to get those
soon.
We want to hear more from the States what they are doing to
recruit more dental providers, to make sure that they are there
to service this population that is out there.
Also, we are exploring with them a lot these other States,
as well, that are in that other range, what are the barriers
that they are seeing, and are they doing anything recently in
terms of dealing with provider rates, and are they taking
action, are they considering action, and what more can we
provide them to help them think those issues through.
Mr. Kucinich. Thank you. As we will hear from the second
panel, there is an inherent problem associated with risk-based
contracts. Risk-based contracts are those written between the
State and the managed care organization that allots a certain
amount of funding for the managed care organization and tells
it if it doesn't use all of the funding for servicing children,
it can keep the excess as profit.
On the other hand, if the managed care organization spends
more than it has been allotted, it has to shoulder those costs.
This clearly creates an incentive for those MCOs to provide
less service for children, and therefore make a profit. In
fact, this was the case in Georgia, where MCOs faced, with loss
of profits, shut down their provider networks, terminating
existing contracts and limiting reimbursement for some of the
most common dental procedures.
So tell me, No. 1, does CMS plan on drafting policy
guidelines for States on how to draft contracts with MCOs in
order to ensure the maximum access and utilization. And,
second, what did you learn specifically about Georgia during
the course of your early periodic screening and diagnostic
treatment review, and could CMS have done differently to
prevent the managed care organizations from limiting
reimbursement and shutting down a dental provider network for
the sake of their profits? Mr. Kuhn.
Mr. Kuhn. On the issue of managed care organizations and
risk contracts, 19 States currently use risk contracting for
coverage for dental services; 15 of the States do it Statewide,
4 or more are kind of geographically limited in terms of the
State. Quite frankly, I think risk contracting has a role in
health care and in this area. It is a chance for us to try to
find incentives to drive greater efficiency in the systems and
try to find ways for better coordination of care, so I think
there is a role for risk contracting that is out there.
Having said that, I think there are opportunities where we
have seen where risk contracting has worked very good. I know I
recently looked at a study out of Minnesota, as well as one out
of New York, where they looked at their Medicaid programs under
risk contracting and showed real good performance, particularly
in the State of New York, for dental care. However, I recently
looked at a study from the State of Kansas, where they showed
better performance on fee-for-service side. So it is a mixed
bag out there. I will be real candid with the subcommittee in
that regard. It is a mixed bag.
So what we are trying to do in terms of our review is look
at those States where they are getting terrific performance
through their managed care contracts and what kind of policy
options can we put forward in that regard.
I am not ready yet to commit to the subcommittee of what
new guidance we might put out there for the States in terms of
drafting contracts, because I don't think we are that far along
in our evaluation. But one of the things I would like to do is
that I am a big believer in greater transparency in health
care, and I have been a very big advocate of what we have done
at CMS in terms of our compare Web sites of getting data out on
nursing homes and hospitals and others. I don't think there is
enough information that is available to the public in terms of
what is going on in dental care that is out there, and so I
want us to be more transparent, and I think MCOs will be one
area that I want to be transparent on as I go forward, so that
I would say is one thing we are going to do in this area. The
other is I think we need to finish our policy work.
In terms of what is going on in Georgia, we haven't
finished that report yet, but I will tell you what we have seen
thus far is that we are concerned with the overall adequacy of
providers in their network in terms of their managed care
organizations. We have already begun talking to the State about
potential improvements that they can make, and we want to have
those further conversations with the State as we go forward.
So basically that is where we are with that State. It looks
like it is a pretty reasonable program they have put together,
but they have hit some issues that we don't fully understand
yet, and, as we finish our investigation, hopefully we will
have more information we can share with you at that time.
Mr. Kucinich. Well, as chairman of this subcommittee I just
want to indicate to you that, with billions of Federal tax
dollars involved in health care in this country, that I am very
concerned about this issue of taxpayers' money going to provide
services and then people not providing the services, having a
structure where you actually incentivize not providing services
so people can make a profit. Because it seems to me that, while
you certainly want to promote the top utilization of services,
you want to promote provider participation, people should be
reimbursed at a rate that is sufficient enough to encourage the
utilization instead of permitting a provider to capitalize on
non-utilization.
This is something I would like you to just give some
thought to, because whenever there is money that hasn't been
used that can be converted into profit, it really opens a door
for service providers to just find a way to game the system, so
I would like you to think about that in your deliberations
about the regulations that you are doing now.
Mr. Kuhn. Those are helpful comments for us, and we will. I
think in that regard what we want to make sure is that, as we
continue to move forward on our efforts here, that we don't be
so prescriptive that we say one size fits all, that this is the
only way that dental services will be delivered in a State;
that we want to make sure States have a menu of options that
are workable, but at the same time we need real accountability
in all these programs, and so I heard you loud and clear, Mr.
Chairman.
Mr. Kucinich. In our May 2007 investigation the
subcommittee uncovered significant deficiencies in availability
of dentists to treat Medicaid patients. Our most recent survey
revealed that such deficiencies are not unique to Prince
George's County, MD. What has CMS done to monitor and insure
that all CMS Medicaid programs have adequate dental networks,
especially those using a managed care model? And, similarly,
what have you done to ensure that State Medicaid payment rates
for dental services are adequate to enroll sufficient numbers
of dentists to provide services comparable to the general
population?
Mr. Kuhn. As part of our 17-State review, we have made a
number of recommendations to States already in terms of what we
think they ought to be doing to improve the adequacy of their
networks.
The other thing that we are looking at pretty hard is to
make sure that we have some better reporting in terms of
quality assessment reports that we get from States on an annual
basis, those States that have managed care organization
contracts for dental providers, and are there ways that we can
improve that reporting, make that information publicly
available so we can create greater accountability out there as
we go forward.
But one of the interesting things I noticed in the report
that you all released on Friday, and, by the way, thank you for
that report. That is going to be very helpful to us and I
appreciate your leadership in doing that.
Mr. Kucinich. Are you surprised by those findings, by the
way?
Mr. Kuhn. No, actually not. They are pretty consistent with
what we are seeing. The one thing, though that was interesting
in terms of that report was that, when you look at a maybe 1-
year or 2-year spread of an individual Medicaid beneficiary in
a program, the dental service access wasn't very great, but as
you got over a longer length of time, 3, 4, 5 years, their
access tends to improve. And so we would like to explore that
more and would like to find some time when we can sit down
perhaps with your staff and others who prepared and worked on
the report to understand some of the dynamics and see if there
is any hypothesis they can share with us in what we saw.
When you look at the data, it looks like you are seeing
better coordination of care over the length of time, and so
those will be helpful things for us to explore with you on a
go-forward basis.
Mr. Kucinich. Thank you. So when you look at the findings,
will you study the pediatric dental programs in Arizona, New
Jersey, and Pennsylvania, to help them improve their programs,
as you are doing in at least 17 other States?
Mr. Kuhn. We would be happy to go and look at those
programs specifically. Certainly.
Mr. Kucinich. Thank you. Now, what is your estimated
budgetary request for next year?
Mr. Kuhn. We haven't begun putting together the fiscal year
2010 budget yet, so I am not sure where we are on that at this
time, but I can get back to you on that one, Mr. Chairman.
Mr. Kucinich. Is it anywhere near $700 billion?
Mr. Kuhn. I don't think so.
Mr. Kucinich. Now, of the estimated budgetary requests that
you will have, we would like to know how much you plan on
allocating to oral health, if you can do that?
Mr. Kuhn. I think we can break that down. I can tell you
right now though that within the Medicaid program roughly 5
percent of Medicaid spending goes for oral health. That has
been fairly consistent over the last several years, so as a
rough gauge that is kind of where we are at this time.
Mr. Kucinich. Well, as you are doing your planning and
reviewing, we would like you to work with us with
recommendations for a legislative agenda, and let us know how
we can help CMS achieve the goals to reform the pediatric
dental program. If we are looking at expanding the scope of
providers, the dental work force has been in decline since the
mid-1990's. Current projections estimate an absolute decline in
the overall number of dentists beginning in 2014. Consider also
that only 2 percent of dentists are trained as pediatric
specialists. This projection will be especially detrimental to
communities who bear the greatest dental disease burden, that
is primarily low-income, inner-city, and rural communities.
I would like to know how does CMS propose creating a more
adequate distribution of professionals to meet the oral health
needs of children.
Mr. Kuhn. That is a good question to pose, and that really
is something that we are looking at and how we can partner with
other agencies like HRSA, the Health Resources and Services
Administration, and others that actually provide training
dollars to schools of medicine to help in the training factor
who run the work force shortage area payment programs, and so
it is our hope that they will be part of our effort as we do
our evaluation, and that there are ways to partner with them to
work with the States and others so we can deal with some of
these distribution issues.
Mr. Kucinich. So are you exploring the potential of
expanding the scope of dental providers?
Mr. Kuhn. Basically, what we are right now is we are really
focused on the issue at hand, the challenge that this
subcommittee laid before us and the challenge we have before us
as an agency, to make sure that we have sufficiency, good
coverage, and great access for children with Medicaid. The
issue that you are raising is one that we have talked about
that I think some time in the future we would like to explore
with sister agencies, but it is not in the work plan now for
what we want to do in the immediate future, but it is something
that we will certainly think about in the future.
Mr. Kucinich. On our second panel we are going to be
talking about focusing on prevention and disease management and
how that helps to create a positive result in a short amount of
time. Will you consider adopting such a model and approach to
addressing oral health?
Mr. Kuhn. Tell me one more time the model, Mr. Chairman?
Mr. Kucinich. The model is approaching oral health by
focusing on prevention and disease management.
Mr. Kuhn. That is certainly models we want to explore, and
one of the witnesses----
Mr. Kucinich. How might you be able to do that?
Mr. Kuhn. Well, one of the things that would be interesting
to explore with the committee, like I said, we are not prepared
yet, because we haven't finished our report, to give you any
legislative recommendations.
Mr. Kucinich. Right.
Mr. Kuhn. But what I can share with you is that some of the
innovations that are going on in the State are terrific, and
you will hear about them on the second panel. I think the work
for the folks in North Carolina, Into the Mouths of Babes, is
just a terrific program. The seed money for that program was
based on some grant funds that came from the Centers for
Medicare and Medicaid Services.
Unfortunately, we don't have that authority right now, so I
think working with you all in the future to look at some
demonstrations designed to look at prevention programs for
high-risk populations would be something that we could begin
talking about now. I would assure you that my staff would
provide any technical assistance your staff would need to help
explore those options.
Mr. Kucinich. I also, before I conclude with this round of
questioning, Mr. Kuhn, I would also like you to think about
another aspect of prevention and disease management, and that
is with respect to parents, especially pregnant mothers. It is
critical to provide dental care and education to child-bearing
women and women of child-bearing age. In 2004, due to a lack of
clinical guidelines, only one out of every five women who gave
birth saw a dentist during pregnancy.
What are your thoughts on this, and will you consider
addressing outreach and care for pregnant mothers in a
prevention and disease management model?
Mr. Kuhn. I would hope that the actions that we are taking
now on the pediatric side would have a great deal of
portability throughout the entire Medicaid program for the
entire dental benefit for everyone, so that what we are doing
here would not be just focused in one aspect but it would cast
the net far and wide and look at the entire enterprise of what
the State does in terms of delivery of dental services.
Mr. Kucinich. But you do get the connection between dental
caries from mother to child?
Mr. Kuhn. Absolutely. And we are focused on the pediatric
side now, but I would hope that, again, what we do here as part
of this effort is across the board with the States as they go
forward.
Mr. Kucinich. And just one final question. Are you going to
be studying risk-versus non-risk-based contracts nationally to
offer policy guidelines to States?
Mr. Kuhn. We are going to be looking at the various payment
models. Yes, sir.
Mr. Kucinich. OK. Final question to Ms. Cackley. I had
asked Mr. Kuhn about this situation where MCOs are getting
funding for servicing children. They are not servicing children
and they walk away with a profit. Have you been able to survey
that in any quantifiable way to be able to address that?
Ms. Cackley. That will part of our ongoing work. In our
surveys to the States, we are looking at and asking them
questions about their MCO contracts and how they are set up and
how they are monitored.
Mr. Kucinich. Let me tell you why that is important,
because as CMS wants to be able to design a more effective
model, it is important to be able to assess the degree to which
the present model has not worked, and it is going to really be
up to you to be able to delve deeply into this question of the
providers who are gaming the system, who have found a way to be
able to keep the so-called excess as profit.
I would like you to look at the MCOs' internal
documentation to see if there is any way in which they
encourage that. I want to find that out, so if you would do
that we would appreciate it.
Ms. Cackley. We would be happy. That is part of our review,
and we will be giving you more information soon.
Mr. Kucinich. Because, Mr. Kuhn, if it is a policy to do
that, that is something you ought to know about.
Mr. Kuhn. You are absolutely right.
You know, we want to make sure that we are looking at all
aspects and that we give a State the options that they need to
do their jobs, but also to make sure that we get accountability
and we get the results that we all want.
Mr. Kucinich. And when all is said and done, to both of
you, this really is about children and making sure they get the
dental health they need so that they have long and productive
and healthy lives. I mean, that is what this is all about.
Ms. Cackley. Absolutely.
Mr. Kucinich. I want to thank both of you for the work that
you are doing. Please continue. We look forward to following up
on this. Thank you so much.
Ms. Cackley. Thank you.
Mr. Kucinich. The first panel is dismissed.
We are going to call the second panel forward.
Thank you very much for being here.
We are fortunate to have an outstanding group of witnesses
on our second panel, and I want to welcome all of you here.
Ms. Susan Tucker is the executive director for the Office
of Health Services for the Maryland Medicaid program. In this
capacity she reports to the Deputy Secretary for the Health
Care Financing Administration, which administers the Maryland
Medicaid program within Maryland Department of Health and
Mental Hygiene.
Over the last 18 months, Ms. Tucker has been involved in
developing and implementing initiatives aimed at improving
access to dental services for low-income children in Maryland.
Mr. Patrick Finnerty is Virginia's Medicaid director and
has served in this position since 2002. He directs all aspects
of Virginia's Medicaid and State Children's Health Insurance
Programs and finance health coverage for more than 715,000 low-
income persons.
Mr. Finnerty has worked in State government for 30 years.
Prior to his current appointment he worked for the Virginia
General Assembly's Joint Commission on Health Care for 8 years,
including 4 years as the executive director.
Dr. Mark Casey is the dental director for the North
Carolina Department of Health and Human Services Division of
Medical Assistance. He is the current secretary treasurer of
the Medicaid S-CHIP Dental Association, also a member of the
National Association of State Medicaid Directors Oral Health
Technical Advisory Group, which has been formed to assist the
Centers for Medicare and Medicaid Services in oral health
policy matters.
Ms. Linda Smith Lowe has been the health policy specialist
with Georgia Legal Services for the past 29 years. Georgia
Legal Services serves 154 of Georgia's 159 counties, including
small cities in rural areas of the State.
Ms. Lowe's involvement with the organization is focused on
Medicaid and PEACH care for kids, Georgia's State children
health insurance program. She also serves on several boards and
works with other nonprofits on these health-related issues.
Dr. Jane Grover has been dental director and clinician for
the Center for Family Health in Jackson, MI, since 2001. She is
the first vice president of the American Dental Association.
Between 1983 and 2001 Dr. Grover was in private practice as a
general dentist. Prior to that she served as dental director of
the Jackson County Health Department in Michigan. She is an
adjunct faculty member of the University of Michigan School of
Dentistry and of the Lutheran Medical Center in New York, and
has taught at Indiana University at South Bend.
Dr. Jim Crall is professor and Chair of Pediatric Dentistry
and director of the National Oral Health Policy Center at the
University of California Los Angeles [UCLA]. Dr. Crall has been
actively involved in national, State, and professional policy
development concerning oral health over the past 15 years. He
was the principal author of Guide to Children's Dental Care in
Medicaid, which was completed under contract awarded by CMS,
then known as HCFA, to the American Academy of Pediatric
Dentistry.
I want to thank each and every one of you for being here
today. I am glad that you had the opportunity to listen to the
two previous witnesses. I am sure that was instructive to you,
as it was to me.
It is the policy of the Committee on Oversight and
Government Reform to swear in all the witnesses before they
testify, so I would ask that you would rise and please raise
your right hands.
[Witnesses sworn.]
Mr. Kucinich. Let the record show that the witnesses have
answered in the affirmative.
As I indicated to those who testified in panel one, each
witness is asked to give a summary of his or her testimony. I
would ask that you try to keep the summary under 5 minutes in
duration. Your written statement will be included in the
hearing record.
Ms. Tucker, let's begin with you. I would ask that you
please proceed.
STATEMENTS OF SUSAN TUCKER, MBA, EXECUTIVE DIRECTOR, OFFICE OF
HEALTH SERVICES, MARYLAND DEPARTMENT OF HEALTH AND MENTAL
HYGIENE; PATRICK FINNERTY, DIRECTOR, VIRGINIA DEPARTMENT OF
MEDICAL ASSISTANCE SERVICES; MARK CASEY, DDS, MPH, MEDICAL
DIRECTOR, NORTH CAROLINA DIVISION OF MEDICAL ASSISTANCE; LINDA
SMITH LOWE, ESQ., PUBLIC POLICY ADVOCATE, GEORGIA LEGAL
SERVICES PROGRAM; JANE GROVER, AMERICAN DENTAL ASSOCIATION; AND
JIM CRALL, DIRECTOR, ORAL HEALTH POLICY CENTER, PROFESSOR AND
CHAIR, SECTION OF PEDIATRIC DENTISTRY, UCLA SCHOOL OF DENTISTRY
STATEMENT OF SUSAN TUCKER
Ms. Tucker. Chairman Kucinich and members of the
subcommittee, my name is Susan Tucker. I am Executive Director
of the Office of Health Services for the Maryland Medicaid
program. Thank you for the opportunity to testify today about
Maryland's efforts to improve access to dental care for low-
income children.
In February 2007 this situation was brought into acute
focus in Maryland with the tragic death of Deamonte Driver.
Since that time Maryland Medicaid has re-energized efforts to
improve dental care for children in Maryland. In the short
term, we have conducted outreach to dental and primary care
providers to remind them of the dental benefits package and
encourage them to refer children to appropriate dental care.
We instructed each managed care organization to verify and
correct their dental provider directories, to directly assist
enrollees in scheduling dental appointments, to submit weekly
reports on enrollee requests for dental care, and we required
MCOs to begin a series of outreach efforts to bring children in
to dental care, including telephone calls, mailings, incentive
plans, and dental education programs. Utilization of dental
services increased from 46 percent in calendar year 2006 to 51
percent in calendar year 2007.
These approaches were an immediate way to address this very
complex problem; however, in order to develop long-term
strategies to improve oral health for children, we needed
significant efforts on the part of dental providers, public
health programs, parents, Medicaid staff, and Federal and State
policymakers.
Governor O'Malley made this one of the first priorities of
his administration by forming a Dental Action Committee, which
included all of these key stakeholders. The committee met
throughout the summer of 2007 to discuss public health
strategies, Medicaid payment rates, alternative delivery models
for the Medicaid program, education and outreach for parents
and caregivers, provider participation, capacity, and scope of
practice.
The committee made 60 recommendations. They highlighted
seven over-arching recommendations for immediate action, with
the goal of establishing Maryland as a national model for
children's oral health care.
Major recommendations that have been or are in the process
of being implemented include increased payment rates. The
Governor's fiscal year 2009 budget included $14 million as a
first installment of a 3-year effort to bring Maryland Medicaid
dental rates up to the 50th percentile of the American Dental
Association's South Atlantic Region.
This multi-year effort is critical to attracting additional
providers. The first year of the fee increase was approved by
the Maryland General Assembly and was implemented on July 1,
2008. The first codes that we targeted were diagnostic and
preventative codes. We paid very poorly in the past on these
codes, but now compare very favorably with other State rates.
Streamlined administration. In order to ease the
administrative burdens for dental providers, the committee
recommended that the Department carve dental services out of
the seven managed care organization service packages and
administer them through a single fee-for-service administrative
services organization. Our long-term goal is to link every
child with Medicaid coverage in Maryland to a dental home where
comprehensive dental services are available on a regular basis.
We do this for pediatricians for children, and we want to do
this for dentists. We believe we will be the first State in the
country to implement such a project.
In the beginning of July 2008 the Department issued a
request for proposals for a single State-wide vendor to
coordinate and administer these benefits for Maryland Medicaid
beneficiaries.
Five entities recently submitted proposals, and we are now
in the process of selecting a vendor. We will be implementing
this by July 2009.
Enhanced public health infrastructure. The Governor's
budget included additional money for dental health public
health clinics in under-served areas. We have opened two new
clinics in areas that didn't have clinics in the past, and more
are planned for the upcoming year.
Increased scope of practice for dental hygienists. The
legislature passed legislation during the last session to allow
for increased scope of practice for dental hygienists working
for public health agencies in Maryland and allowed them to
provide those services offsites.
The Dental Action Committee continues to meet regularly.
This is a working, action-oriented committee. They have been
asked by the Secretary not to write reports that will sit on a
shelf, but instead to design practical, workable initiatives
and to bring all parties in the State together to solve this
difficult problem. They have the support of staff throughout
the Department of Health and Mental Hygiene.
One key subcommittee is developing a unified oral health
message to encourage oral health literacy for all Marylanders.
No child should wait until they are in pain to seek and receive
dental care.
Another committee is developing a pilot program for dental
screenings in schools. Still another is training general
dentists on how to provide high-quality dental services to
young children.
We are also fortunate that Congressman Elijah Cummings has
provided a constant Federal presence by working to ensure that
children have access to dental care in Maryland. He included
language in the State Children's Health Insurance Program to
guarantee dental benefits and introduced Deamonte's Law, which
would enhance the dental safety net and work force by
increasing dental services in community health centers and
training more individuals in pediatric dentistry. We value his
leadership in this important public health arena.
Maryland is committed to implementing the Dental Action
Committee's recommendations to ensure access to oral health
services for all children on Medicaid. We need to increase the
number of dentists willing to see children with Medicaid and to
increase the awareness of the benefits of basic oral health
care among our enrollees.
Although it is too early to report on the impact of these
long-term initiatives, we will regularly evaluate their
success, as indicated by utilization of services, provider
network adequacy, and health outcomes. We will remain flexible
and will seek innovative ideas for adjusting our strategies as
we move forward.
Thank you.
[The prepared statement of Ms. Tucker follows:]
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Mr. Kucinich. Thank you very much.
Mr. Finnerty.
STATEMENT OF PATRICK FINNERTY
Mr. Finnerty. Good morning, Mr. Chairman and members of the
subcommittee. My name is Patrick Finnerty, and I serve as the
Medicaid Director for the Commonwealth of Virginia. I am
pleased to appear before you this morning to review the
significant changes and resulting improvements in our Medicaid
and SCHIP dental programs.
In Virginia we serve about 450,000 children through our
Medicaid and SCHIP programs. Soon after becoming the Medicaid
Director it was clear to me that our dental program for
children was not functioning very well.
As seen on slide two, fewer than 24 percent of our children
received any dental service in 2003. One of the key reasons for
this was that our dental provider network was inadequate. Only
about 13 percent of licensed dentists in Virginia were
participating in our program. Of that number, only about one-
half of them were actively seeing Medicaid and SCHIP children.
While we had a pretty good idea what the problems were, we
sat down with the leadership of the Virginia Dental Association
and heard loud and clear that we needed to make some changes.
First, our reimbursement was very low and far below what
dentists were being paid by commercial carriers. Second, they
identified a number of administrative hassles that needed to be
removed, such as outdated billing procedures, overly burdensome
prior authorization requirements, and poor responsiveness to
provider concerns.
They also felt our managed care program was not working for
them. Overall, managed care has been a very successful program
in Virginia; however, our dental providers had several
concerns, including having to deal with multiple plan
requirements, credentialing, and patients transferring between
plans in the middle of treatment. Last, a significant concern
was patient no-shows when patients fail to keep their scheduled
appointments.
After getting a clear understanding of the changes that
were needed, we created an entirely new program and declared
that it was a new day for dental in Virginia. We adopted a new
program name, Smiles for Children, re-branded it with a new
logo, and essentially started over.
The new program was developed through ongoing and close
collaboration with the Virginia Dental Association and the Old
Dominion Dental Society. We were very fortunate to also have
tremendous support from the Governor and the Legislature, who
authorized us to implement a completely restructured program
and approved an unprecedented 30 percent increase in fees.
These actions did two things. First, it gave us the
necessary authority and funding to implement our new program,
but, equally important, it communicated to the dental community
a commitment to work with them to improve access to dental care
in Virginia.
Smiles for Children was launched on July 1, 2005. Leading
up to that date and ever since then, the support for the
program from the dental community has been outstanding. Dr.
Terry Dickenson, the Executive Director of the Virginia Dental
Association, has been and continues to be a great champion and
advocate of the program.
Let me quickly review the major elements of our reform.
First, we carved out dental services from the five managed care
companies, and now all children have their dental services
administered by one vendor, Doral Dental. Through our
contractual relationship, we pay Doral an administrative fee to
manage the program for us. It is a fee-for-service program
wherein providers bill Doral and Doral pays the provider with
funds that we make available. Neither Doral nor providers are
paid on a capitated basis.
In the old program, providers had to deal with multiple
credentialing requirements in order to participate. With Smiles
for Children there is one streamlined process.
I mentioned earlier our providers had identified several
administrative hassles in the old program. We now have industry
standard administration.
Prior to Smiles for Children, Virginia dentists had little
involvement in program decisions. Now we have a Virginia Peer
Review Committee and a Dental Advisory Committee.
Last, by having all of the children in one dental services
program, the potential for disruption of care that can result
from children moving among different plans has been eliminated.
We also established a dedicated dental unit within our
agency to work with providers and monitor the program.
Slide five summarizes the administrative improvements and
other benefits that Smiles for Children provides for our
participating dentists. I am not going to review each of them,
but they represent important industry standard components of
benefits administration that our dental partners were looking
for.
I would like to now focus on the results of our efforts.
Following the start of our new program in July 2005, the
number of participating dentists has increased 80 percent, and
our network continues to expand each month. There are a handful
of localities in Virginia which, prior to Smiles for Children,
had no participating dentists, and now there is access to a
dentist in their community.
A key indicator of our success is that a higher percentage
of providers are actively billing for treatment, and our
provider and patient surveys show a high level of satisfaction
with the program.
More importantly, our program reforms have resulted in
greater access to care for Medicaid and SCHIP children. As
illustrated in slide seven, for children ages zero to 20 the
percentage of eligible children receiving necessary dental
services has increased 50 percent from 2005 to 2007. For
children ages 3 to 20, we have seen a 55 percent increase.
We believe that these increases are the result of the two
major elements of our reform--the complete redesign of the
program and the 30 percent increase in fees.
Last, I just want to note that Virginia's reforms have
received a good deal of national attention. Over the past few
years, we have been asked to present at national meetings of
the American Dental Association, the National Association of
Dental Plans, the National Association of State Medicaid
Directors, the Medicaid Managed Care Congress, the National
Academy for State Health Policy, and the National Oral Health
Conference.
The successes we have achieved have come as a result of
everyone working together for the same cause, that being
increased access to dental care for low-income children.
Organized dentistry has been very supportive and helpful, and
they are a true partner in this. The Governor and General
Assembly have given us the tools, resources, and support to
make these improvements.
We recognize that, while there have been marked
improvements, far more children need to be receiving dental
services, and we are working toward that goal. We continue to
look for further enhancements to the program and will keep this
issue as a high priority in Virginia.
Mr. Chairman, that concludes my prepared testimony. I
appreciate the invitation to be here today, and I am happy to
answer any questions you may have.
[The prepared statement of Mr. Finnerty follows:]
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Mr. Kucinich. I thank the gentleman.
We are going to declare a half hour recess. There are votes
on right now. I ask the witnesses to please return in a half
hour. If there are any difficulties with that, check with my
staff. This committee stands in recess for a half hour.
Thank you.
[Recess.]
Mr. Kucinich. Thank you very much. We are going to continue
the hearing. The only need for a break will be if there are
more votes. I want to thank you for your patience.
I would ask, with the committee now having come to order
again, if Dr. Casey would proceed with your testimony.
STATEMENT OF MARK CASEY
Dr. Casey. Good afternoon, Mr. Chairman. I would like to
thank you for the opportunity to testify about reforms to
pediatric oral health care in Medicaid.
My name is Dr. Mark Casey, and I am the Dental Director for
the North Carolina Department of Health and Human Services
Division of Medical Assistance. I am proud to highlight the
Into the Mouths of Babes or IMB program, one successful
strategy to improve oral health for low-income children in the
State of North Carolina.
About 40 percent of all children enrolled in kindergarten
in North Carolina have experienced tooth decay, and this figure
can reach as high as 70 percent in some counties. As we know
from the tragic death of Deamonte Driver, untreated dental
disease in children can have devastating systemic consequences.
In addition, there are tremendous societal costs to
families and others involved in the care of children that
cannot be easily estimated--missed time at work, missed school
time, time and money spent trying to find care for a child with
dental problems. The lists of these costs is potentially
endless.
In North Carolina we found that there were not nearly
enough dental resources available to address the problem of
Medicaid preschool children through traditional delivery
methods, so we turned to non-dental health care professionals
for a preventive strategy to manage the chronic and widespread
problem of early childhood caries or cavities.
Preventive oral health care services are easily integrated
into practices of primary care medical practitioners during
well child visits, which occur at frequent intervals in the
very first few years of life. The network of Medicaid enrolled
primary care physicians in North Carolina was robust and
distributed throughout all the counties of the State. All the
elements of sustainability were present to translate this
approach into success for a preventive program in primary care
medical settings.
After demonstration and pilot projects in limited areas
which were supported by Federal funds, IMB was launched State-
wide in 2001. To date we have trained more than 3,000
pediatricians, family physicians, nurses, and other types of
health care professionals to conduct oral evaluations and
detect oral pathology, assess risk for oral disease, counsel
parents and/or caregivers about oral hygiene and nutrition, and
apply fluoride varnish, the safest and most effective form of
topical fluoride for the target population of children.
More than 400 primary medical practice sites are currently
participating providers in the IMB. From the inception of the
program, the goals of the IMB have been to increase access to
preventive dental care for low-income children zero to 3 years
of age, reduce the incidence of early childhood caries in low-
income children, reduce the burden of treatment needs on a
dental care system stretched beyond its capacity to serve young
children.
As it has matured, IMB has increasingly emphasized
effective dental referrals for recipients, particularly those
children at elevated risk for disease.
The IMB program has resulted in a substantial increase,
about 30-fold, in access to preventive oral health care
services. Even in the early implementation phase of IMB,
children from every County in North Carolina were receiving
these services. In as many as one-third of the State's
counties, no child received any preventive care in dental
offices before implementation of the program. The IMB has had a
positive effect on overall access for Medicaid children of all
ages in North Carolina during any 1 year.
The IMB research team has conducted systematic analyses to
assess the effectiveness of the program. This research has
demonstrated a statistically significant reduction in
restorative treatments for anterior teeth that increased with
age. By 4 years of age, the estimated cumulative reduction in
the number of restorative treatments was 39 percent for
anterior teeth.
IMB has led to an increase of access to treatment services
to the effect of referral of children with pre-existing disease
at the time of the initial physician visit to a dentist.
Children who are identified by their physician as having dental
caries, when provided with a referral to the dentist, saw the
dentist sooner than children with no dental caries who were not
referred.
We have gathered evidence that physician services are not a
substitute for care in the dental office but supplement
preventive care being rendered by dentists for Medicaid infants
and toddlers.
Taken together, these findings suggest that the IMB program
both prevents early occurrence of dental disease and promotes
earlier entry into the dental care system for those children in
greatest need.
It is important to note that Federal funding played a very
vital role in the success of the IMB program. Funding from the
Appalachian Regional Commission, CMS, the Health Resources and
Services Administration, and the Centers for Disease Control
and Prevention allowed Medicaid and partners in North Carolina
to further develop our innovative approach to the prevention of
early childhood caries. In particular, the funding provided for
staff to develop the curriculum for training, conduct the
training, and generally oversee the substantive aspects of the
program and generate the science supporting the innovative
program.
In our opinion, the one-time funding initiative from CMS
and other Federal agencies provides an excellent model for one
strategy that could stimulate innovative thinking about new
approaches to increasing children's access to dental care.
Renewal of this funding program would result in new
approaches beyond the medical model developed in North Carolina
and would yield oral health benefits to children enrolled in
public insurance nationwide. Federal sources of funding
continue to make a difference in the sustainability of IMB.
Treatment services provided in the program are supported
through the Federal Medical Assistance Percentage FMAP funds,
matching State appropriations. Current evaluation and research
efforts are supported by HRSA and the National Institutes of
Health. Initial achievements and the continued success of the
IMB would not be possible without the active financial support
the Federal agencies have provided over the life span of the
program.
The IMB partnership has moved beyond the original blueprint
for the program to consider methods to improve the quality of
program treatment services and extend the preventive model.
Current expansion strategies focus on refining caries risk
assessment tools used by both dentists and physicians and
training them in their use, training general dentists to
provide care for infants and toddlers, improving communication
between primary care medical providers and dentists to
facilitate referral when necessary due to elevated risk for
dental disease, coordinating patient care to ensure parents
and/or caregiver compliance with treatment regiments, and
formulating oral health education initiatives targeted to
parents and/or caregivers.
The IMB team believes that the future looks bright for the
program as we develop new ways to extend its success. IMB
advocates are also encouraged by reports of the adoption of a
similar model to provide preventive services for Medicaid
children in many States throughout the country. We are proud to
be at the forefront of this movement and stand ready to assist
other States as they plan, develop, and implement similar
programs.
On behalf of the many partners in the IMB collaborative, I
thank you for allowing me to bring well-deserved national
attention to this important North Carolina dental public health
initiative.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Casey follows:]
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Mr. Kucinich. Thank you very much, Dr. Casey.
Ms. Lowe, please proceed.
STATEMENT OF LINDA SMITH LOWE
Ms. Lowe. Good morning, Mr. Kucinich. Thank you, Mr.
Chairman. My name is Linda Lowe. I really appreciate the fact
that you are having these hearings on this critical topic of
our children.
Like children in most States, Georgia's low-income children
have poor dental health. In 2005, 56 percent of our third
graders had tooth decay, and 27 percent of the children had
untreated decay. School officials continue to say that a major
reason for students' absences from school and their poor
academic performance has to do with their lack of dental care.
Getting oral health care right under Medicaid could make an
enormous difference for this generation of children. In 2005,
63 percent of Georgia's children had either Medicaid or PEACH
Care, which is our State child health insurance program. Many
other children were eligible but not enrolled.
Your staff asked me to highlight Georgia's experience with
dental care for children over the last decade. Georgia's story
is one of somewhat successful multi-year efforts that saw some
dentists accept Medicaid patients and produced noteworthy
increases in utilization rates for children. Unfortunately, it
also shows that budget cutbacks can too easily reverse such
advances, and that moving to capitated managed care is no
panacea.
Just a little history: in 1999 advocates and dentists
raised an alarm about Georgia's poor and diminishing access to
oral health care for children. Medicaid dental reimbursement
was about 30 to 40 percent of average customary fees. A
Statewide referral hotline had located only 257 dentists
willing to take new Medicaid patients, far too few to meet the
need in our State, which is the largest geographically east of
the Mississippi.
In response, the State very wisely enacted a rate increase,
raising reimbursement to about $0.50 on the dollar. It also
took concrete steps to simplify billing.
Two years later, the State raised rates to the 75th
percentile, and afterward provided an inflationary increase.
Also at that time Georgia moved to more electronic claims
processing with instant online information about patient
eligibility and claim status.
During this period, more dentists began to accept Medicaid
patients. Between 2000 and 2005, the number filing at least one
claim per week increased by 57 percent to over 1,000. Also, a
mobile dental service, which was the innovation of a Georgia
practitioner, started operations and now serves children at
school in 76 counties.
Over 5 years, our children's utilization rates, as shown on
the CMS 416, made steady progress. The proportion of children
receiving any dental service, preventive dental services, and
treatment services rose from below 20 percent to about one-
third of all children, and it really seemed that children's
oral health care was on the right track.
Then in fiscal year 2004 a State budget crisis led
officials to eliminate reimbursement for a number of
restorative dental services, cutting a total of 7.5 percent
from the dental budget. In 2005, although the proportion of
children receiving preventive dental services continued
improving slightly, the proportion receiving treatment plunged
from 34 percent to 19 percent and went down again the next year
to 17 percent.
In mid-2006, announcing its intention to save money and to
improve access, Georgia required most Medicaid and all PEACH
Care children to enroll in one of three capitated managed care
organizations that we call CMOs. The CMOs would be responsible
for almost all of their services, including dental care.
At first the CMOs kept fees where they were, but that soon
changed when they saw higher than expected utilization eating
into their profits. They required more prior approvals,
adjusted fees, and began closing networks. Two of them
terminated their contracts with the dental organization that
had served over 40,000 children.
Dentists complained that the CMOs and their subcontractors
have added new levels of administrative difficulty, not to
mention cost. In addition, some dentists say it is harder to
find specialists who will accept referrals. Although the CMOs
list large networks of dentists, data from the State show that
large number of the CMOs' dentists have not filed a single
claim.
It is too soon to know whether CMOs are making a difference
in children's health care one way or the other. The first year
of implementation is the latest for which we have data. The
utilization rates remain close to the same as the year before
CMOs began operation when treatment rates had dived. It will
take systematic data collection and analysis to see how well
children are actually doing.
It would be worth evaluating the mobile school-based
approach which claims 65 to 70 percent of their Medicaid
children complete treatment, which they say is far more than
the children in their office practice, which includes children
with other kinds of insurance. While it is not the traditional
model of a dental home, it helps solve the problems of
inadequate transportation, a parent having to forego a day of
earnings to take children to the dentist, and the no-shows that
hinder efficient operations in a dentist's office.
My testimony that is written lists a number of
recommendations, some of which address issues I haven't had
time to talk about here, but, once again, I want to thank you
for your attention and for your concern about the problem with
children's oral health.
[The prepared statement of Ms. Lowe follows:]
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Mr. Kucinich. Thank you for your testimony and your
complete testimony, as well.
Dr. Grover.
STATEMENT OF JANE GROVER
Dr. Grover. Good afternoon, Chairman Kucinich and members
of the subcommittee. My name is Dr. Jane Grover. I am very
pleased to be here today representing the American Dental
Association. In addition to being an ADA officer, I serve as
the Dental Director for the Center for Family Health in
Jackson, MI, a federally qualified health center. I also serve
as a Medicaid reviewer for the Michigan Department of Community
Health.
As the Dental Director in an FQHC and as an experienced
private practitioner before that, I understand the problems
with the dental component of the Medicaid program. In my
opinion, we need to take three actions to properly care for the
Medicaid population.
First, get many more dentists into the system, which is the
primary focus of this hearing. Second, influence the geographic
distribution of those dentists to make sure they can serve the
Medicaid population in a timely fashion. Third, support other
oral health initiatives that strengthen the oral health
delivery system.
I address all of these points in my written testimony;
however, in the interest of time I am going to focus primarily
on the first point, attracting dentists to the Medicaid
program.
A March 2008 study funded by the California Health Care
Foundation confirmed what the ADA has been saying for some
time: to improve dentists' participation in Medicaid, the
States must improve fees, ease administrative burdens, and
involve dentistry as an active partner. The Foundation's report
examined six States where the number of participating dentists
and patients seen in the Medicaid program rose significantly.
For purposes of my testimony, I will focus on the Michigan
Healthy Kids Dental Program, which is essentially the same as
the private sector Delta Dental Plan used by many people with
coverage provided by their employers. Dentists are paid at a
PPO rate, which might be less than the usual rate charged, but
is still widely accepted.
The claims processing is identical to the private sector
plan, except that beneficiaries have no co-pays and there is no
annual maximum.
From the dentists' perspective, there is no difference
between the Healthy Kids Dental Program and the widely accepted
Delta Dental private plan. For patients, the stigma associated
with being on Medicaid has been removed. Families cannot be
differentiated into Medicaid and non-Medicaid groups. And the
Healthy Kids Dental Plan has been a resounding success.
Dentists' participation shot from 25 percent to 80 percent
1 year after the program was introduced and now stands at 90
percent. The travel time to a dental office was cut in half,
equaling that of the private sector Delta Dental Plans. The
number of children with a dental home under the program far
exceeds those with a dental home under the traditional Medicaid
program in Michigan.
Unfortunately, about two-thirds of the Medicaid eligible
children remain in the traditional Medicaid program in
Michigan. More needs to be done to bring all of the eligible
children into the Healthy Kids Program.
We believe CMS can help by issuing guidance outlining how
such collaborative activities have effectively worked in
Michigan, Alabama, Tennessee, and other States. In addition, a
letter from CMS to State Medicaid directors requiring them to
report on steps they are taking to improve their dental
Medicaid programs would also help.
The ADA also believes passing H.R. 2472, the Essential Oral
Health Care Act, is important because the bill provides
enhanced Federal matching funds if a State is willing to
increase Medicaid fees, address administrative barriers, and
reach out to the dental community.
Finally, regarding initiatives that strengthen the oral
health delivery system, Mr. Chairman, we agree with the
Congressional Research Service where, in its September 18,
2008, letter to this subcommittee, the agency identified
barriers affecting the use of dental service among children.
Those barriers include navigating government assistance
programs, finding a dentist willing to accept Medicaid,
locating a dentist close to home, transportation to a dental
office, cultural and language barriers, lack of knowledge about
the need for pediatric oral health care.
The ADA is seeking funding to conduct demonstration
projects for a potential new dental team member, the community
dental health coordinator, designed to address those barriers.
We describe the CDHC fully in our written testimony.
Thank you, Mr. Chairman, for this opportunity to testify. I
would be pleased to answer any questions.
[The prepared statement of Dr. Grover follows:]
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Mr. Kucinich. Thank you very much.
Dr. Crall, you may proceed. Thank you.
STATEMENT OF JIM CRALL
Dr. Crall. Thank you, Mr. Chairman. And I thank members of
the subcommittee for the opportunity to participate in this
hearing.
My comments today largely focus on the impact of Medicaid
reimbursement rate increases on dentist participation and
children's utilization of dental services in Medicaid, and the
benefits of no-risk contractual arrangements that separate or
carve out Medicaid dental benefits from global Medicaid managed
care arrangements.
Access to an ongoing source of comprehensive dental care is
a critical component for maintaining good oral health in
children. Access to a dental home or regular source of dental
care is especially important for children who are at elevated
risk for tooth decay, predominantly children in low-income
families and children with special health care needs, children
typically covered by Medicaid.
National surveys showing an increase in tooth decay in
young children, what we now call early childhood caries,
combined with the already large and growing numbers of children
on Medicaid underscore the need for engaging substantial
numbers of dentists as Medicaid providers across the United
States. However, chronically low reimbursement to dentists for
services rendered has been acknowledged by several private and
governmental reports to be a major, if not the greatest,
barrier to dentist participation in Medicaid.
Access to dental services for children covered by Medicaid
is a significant and chronic problem. Studies conducted by the
U.S. Department of Health and Human Services in 1996 reported
that, A, relatively few children covered by Medicaid received
recommended dental services; and, B, inadequate reimbursement
is the most significant reason why dentists do not participate
in Medicaid.
The GAO's April 2000 Report to Congress indicated that the
level of Medicaid dental reimbursement in 1999 nationally and
in most States was about equal to or less than the 10th
percentile of respective fees; that is, at least 90 percent of
dentists charged more, and usually substantially more, than the
Medicaid fee.
A subsequent assessment conducted in 2004 by myself and Dr.
Don Schneider, former Chief Dental Officer at CMS, found that
in 41 States the majority of dental Medicaid reimbursement
rates for common children's dental procedures remained below
the 10th percentile, and frequently were below even the first
percentile of dentists' fees, meaning that the Medicaid rates
were lower, and often substantially lower, than the fees
charged by any dentist in the respective States.
Beginning in the 1990's, following a series of Oral Health
Policy Academies organized by the National Governors
Association, several States moved to increase Medicaid
reimbursement levels to considerably higher levels consistent
with the market-base approached advanced in the NGO Oral Health
Policy Academy. As shown on the table on this slide, subsequent
evaluations suggest that, similar to the findings by the GAO,
Medicaid payments that approximate prevailing private sector
market fees do contribute to increased participation by
dentists in Medicaid.
Other States, including Virginia, Texas, and Connecticut,
also have taken steps to raise their Medicaid dental
reimbursement rates to what are considered reasonable, market-
based rates. Unfortunately, as in the case of Connecticut and
Texas, these changes often follow years of protracted
litigation in Federal courts.
The table on the next slide provides a comparison of Texas
Medicaid payment rates for selected procedures and fees charged
by dentists within the State of Texas. This chart basically
illustrates comparisons that are typical of many other States.
You can see that in 2004, for example, for a periodic oral
examination, or Code D-0120, that the Texas payment rate of
$14.72 was roughly half of what the 50th percentile or average
rate fee that dentists charge.
More strikingly, if you look at the far right column on
this table you will see that for 11 of the procedures that we
normally monitor to try to assess adequacy of payment levels in
Medicaid, that the Texas rates, as is true in many, many other
States, was below the first percentile, or below what any
dentist considers a reasonable charge for those services.
In September 2007, however, following a settlement in the
Federal court case of Frew v. Hawkins, Texas EPSTD dental
Medicaid reimbursement rates for 35 common procedures were
raised by 100 percent, effectively to the 50th percentile of
Texas dentists' fees. This action followed more than a decade
of essentially stagnant dental Medicaid rates in the face of
steady modest increases in the cost of dental care, typically
between 4 and 5 percent per year.
Significant increases also were provided for approximately
20 additional relatively common dental procedures.
Information obtained from individuals involved in the Frew
case indicates that following Medicaid reimbursement rate
increases in Texas the State has issued approximately 500 new
Texas Medicaid dental provider numbers. The actual number of
new dentists in the program is not clear at this time because
in Texas a dentist may have more than one provider number if
they operate in multiple locations.
The entire section of the document that the AAPD submitted
to the Health Care Financing Administration, now CMS, on
program financing and payments, Section C in the submitted
table of contents, was deleted from the published version of
the Guide to Children's Dental Care in Medicaid. Topics
addressed within that section are delineated within my written
testimony.
Additional information provided in the Guide showed that
roughly $14 to $17 per enrolled beneficiary, often referred to
as PMPM, or per member per month, would be necessary to pay for
dental services for children enrolled in Medicaid at market
rates comparable to those used by commercial dental benefit
plans for employer-sponsored groups. Typical benefits
administration rates would raise those levels to $17 to $20
PMPM.
A subsequent actuarial analysis commissioned by the
American Academy of Pediatric Dentistry in 2004 generally
affirmed those findings; however, available information
suggests that many States allocate only a small fraction of the
financial resources suggested by these actuarial studies,
oftentimes on the order of $5 to $7 per beneficiary per month.
Now, shifting to the impact of Medicaid rates on increases
in children's use of dental services, perhaps more directly to
the point, the table on the next slide shows data from CMS 416
annual reports illustrating significant increases in
utilization of dental services by children covered by Medicaid
in five States following significant reimbursement rate
increases.
The increased use of dental services demonstrated in this
slide also constitutes a significant positive impact of
Medicaid dental reimbursement rate increases.
The rate increases, which have been implemented in these
and a handful of other States, were not done in isolation; they
are generally part of a broader combination of actions designed
to address issues which have been identified as chronic
barriers to dentist participation and access to dental care in
Medicaid.
Although addressing these other issues is viewed as an
important element of comprehensive dental Medicaid program
reform, increasing Medicaid rates to reasonable, market-based
levels is critical to obtaining adequate levels of dentist
participation in Medicaid.
Finally, commenting on the topic of the advantages of no-
risk contractual arrangements or carve-outs for dental Medicaid
benefits, in addition to the essential step of raising Medicaid
dental reimbursement rates to reasonable, market-based levels,
many States also have taken steps to implement no-risk or
administrative services only, ASO, contracts that separate or
carve out dental Medicaid benefits from global Medicaid managed
care arrangements. Examples include Michigan's Healthy Kids
Dental Program and Medicaid dental programs in Connecticut,
Maryland, Tennessee, and Virginia.
Such arrangements eliminate the need for subcontracting
between global Medicaid managed care organizations, which often
are not in the business of providing dental benefits, and
dental benefits managers. This change not only helps to
simplify program administration and reduce confusion among
dentals and Medicaid beneficiaries, alike; the no-risk aspect
also helps to eliminate the inherent incentive in risk-based
contractual arrangements for managed care organizations and/or
dental benefit managers to reduce payments to dentists in order
to enhance the intermediary's profits.
In addition to simplifying the administration of Medicaid
dental benefits, these arrangements allow States to retain
greater control in establishing reimbursement rates while
affording reasonable profits for dental benefits managers.
Additional advantages of the single vendor approach, as was
mentioned for Virginia, from the dentists' perspective include
more streamlined enrollment procedures, because dentists do not
need to fill out multiple enrollment forms and undergo
credentialing by multiple dental benefits management
organizations, and less confusion about program policies
governing allowable services and billing processes, which often
results from having multiple intermediaries.
Moreover, contracting with a single dental Medicaid
intermediary or a single vendor simplifies the contracting
process, improves the ease of program monitoring, and has the
potential for better contract enforcement on the part of State
Medicaid programs.
So, in summary, several States have taken significant steps
to increase dentist participation and access to dental services
in their Medicaid ETSDP programs over the past decade.
Successful efforts generally have involved the necessary step
of raising Medicaid dental reimbursement rates to reasonable,
market-based levels, combined with additional steps to make
Medicaid dental program administration more dentist friendly.
Streamlining provider enrollment and implementation of no-risk,
contractual arrangements that separate or carve-out Medicaid
dental benefits contracting from global Medicaid managed care
arrangements have been prominent parts of these strategies. In
my opinion, promoting the adoption of these strategies by other
States would help to substantially improve children's access to
dental care and Medicaid.
Overall, basically we need to give credit for the States
that have demonstrated leadership in reforming their dental
Medicaid programs for children; however, clearly more
systematic efforts are necessary, and additional congressional
and regulatory assistance, whether it be in the form of an
increase in the FMAP rates, loan repayment or loan forgiveness
for dental school faculty and new dentists entering practice,
or demonstration programs are needed and would be welcome.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Crall follows:]
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Mr. Kucinich. Thank you very much, Dr. Crall.
I would like to go to questions of members of the panel. We
will begin with Ms. Tucker.
In conversation with my staff, you mentioned that the
number of dentists in Maryland is so limited that, even if they
all enrolled in the Medicaid provider network, you still would
not have enough dentists to service the State's Medicaid
population. What are you doing to increase the number of
dentists in Maryland, or what are you thinking of doing?
Ms. Tucker. What have we been doing and what are we going
to be doing?
Mr. Kucinich. Yes.
Ms. Tucker. We have entered into dialog with our Maryland
chapter of the Dental Association and other dental associations
in Maryland, and we have asked them to come to the table and
participate in the Medicaid program. We have told them that we
will increase payment rates, and we did in July.
They just had their annual meeting. At their annual
meeting, we had all our dental vendors there and helped them
enroll in the program, so we actually had people there and
assisted with that.
In the long run, we are moving toward a single vendor,
which is one administrative service organization that is fee-
for-service. The dentists have said that they will be more
likely to participate, and many have said they won't
participate until that move is made.
So we have kind of been working on short-run efforts. We
did enroll people during the last week at the convention, but
we are also looking at the long-term changes.
Mr. Kucinich. Well, you have obviously made some great
strides in your pediatric dental program.
Ms. Tucker. Right.
Mr. Kucinich. What has provided the political will for such
a change?
Ms. Tucker. Which provided what?
Mr. Kucinich. What has provided the political will for the
strides that you have made in improving pediatric dental care?
Ms. Tucker. I think the fact that it is a new Governor.
This terrible tragedy occurred in our State. He made it a major
priority of his administration. He pulled together all of the
important stakeholders throughout the State, and our Secretary
chaired the Dental Action Committee. We had everybody at the
table making recommendations. Everybody was committed. They
made very concrete recommendations that we could actually carry
out.
Mr. Kucinich. And could you tell me what have you learned
about having multiple MCOs providing pediatric dental care to
Medicaid enrollees?
Ms. Tucker. Well, one thing that we learned, during the
time when we had implemented the health choice program we
actually had seen increases in utilization of services for
children, but it wasn't enough. What we did learn was that this
provider community is not willing to accept any administrative
burdens. It is a provider community that actually doesn't like
insurance as a whole, and is very able to survive with patients
that are private fee-for-service patients. So one thing that we
learned was that any administrative burdens caused by having
multiple organizations was a real problem for this provider
community. That was one thing that we definitely learned, and
we are moving forward with this single vendor because of that.
Mr. Kucinich. Thank you very much.
Dr. Grover, the New York Times reported that the number of
dentists in the United States has been roughly flat since 1990
and is forecast to decline over the next decade. Can you tell
us how many dentists graduate each year and how many retire?
Also, what is the total number of dentists? Is there a dentist
shortage? How do we meet the growing public need for oral
health services with the population of dentists remaining
static?
Dr. Grover. Well, the particulars of the number that
graduate from the 57 dental schools that we have now I don't
have with me right now, but I would be happy to provide that. I
can say that there are seven new dental schools that are
opening, and the number of dentists in this country, some may
say that there is a maldistribution of dentists. Clearly, there
are dentists needed in areas where there are currently no
access to oral health services. And there are States that are
experimenting with loan forgiveness and other incentives to
attract providers to those areas.
The exact number of dentists that are retiring is a fuzzy
number. There are some that retire and then come back into
practice. We have had a private practitioner retire and came
and joined our staff at our health center. It is a fluid
number.
Mr. Kucinich. Thank you. In your testimony you discuss a
community dental health coordinator who would be responsible
for such dental procedures as fluoride and sealant
applications, as well as performing temporization on dental
cavities with materials designed to stop the cavity from
getting larger. What is the difference between a community
dental health coordinator and a dental hygienist, and if a
difference exists, why can't a dental hygienist perform these
procedures?
Dr. Grover. Well, a dental hygienist can do the duties that
we have outlined with the community dental health coordinator.
The difference is that a hygienist is most effective and most
productive in performing clinical services with a dentist. The
community dental health coordinator is meant to be a community
worker with oral health skills. That is a person who helps
these wonderful people navigate a very complicated system,
helps get families enrolled, helps patients keep their
appointments, and helps with transportation issues, which in my
personal experience is one of the biggest barriers that this
population faces.
So the community dental health coordinator is certified,
not licensed, and can perform procedures, but primarily
functions as a navigator and oral health educator.
Mr. Kucinich. You mention that one of the reasons dentists
are not interested in participating in Medicaid is because of
the administrative burdens. Do you believe that carving out
dental from managed care structure would work to ease those
burdens and therefore attract more dentists?
Dr. Grover. Well, I can only speak from the Healthy Kids
perspective. I know what a success it has been in Michigan. I
know that in my health center we have had great success with
helping our community become more involved. Healthy Kids dental
has been a success story in Michigan because of the
streamlining that they have done. Other MCO organizations I
can't really speak for.
Mr. Kucinich. Thank you very much.
Dr. Crall, in your testimony you suggest that risk-based
contracts have a built-in incentive to reduce payments to
dentists who provide dental services to Medicaid beneficiaries.
Why is that?
Dr. Crall. Well, basically if the organizations are paid on
a capitated basis it creates an incentive to reduce their
payout. That contributes to their bottom line. There are
multiple ways in which that can be done. If reimbursement rates
or payments to dentists are kept low, that will suppress the
supply of services. If administrative burdens are put in place
that require preauthorization that isn't consistent with what
dentists experience in other commercial plans nor plans that
are not risk-based, then those are ways in which the supply of
dental services will be constrained, which contributes directly
to the bottom line of the organization.
Mr. Kucinich. So why do States continue to enter into risk-
based contracts in MCOs?
Dr. Crall. States, certainly over the period of the last
decade or so and in the current clime, are faced with some
fiscal pressures, budgetary pressures.
Mr. Kucinich. That is why you would maintain----
Dr. Crall. And the global managed care arrangement is a way
to sort of try to cap the increases in the health care costs.
Mr. Kucinich. Do you have any opinion on whether States
should enter into non-risk-based contracts?
Dr. Crall. I will reiterate the opinion in my testimony,
which is, in fact, I think, that non-risk-based approaches such
as was used in Tennessee in a global managed care arrangement
that was very much risk-based, when the dental piece was carved
out in Tennessee there were substantial and very rapid sort of
increases in dentists' willingness to participate, and in the
State's ability to manage that program more effectively.
Mr. Kucinich. Well, you kind of answered part of this
previously, but States have a limited amount of funding, have
to make difficult decisions on how to allocate. If States were
considering increasing reimbursement rates for a limited number
of procedures, which ones would you recommend be prioritized?
Dr. Crall. Without getting into too much detail, I was
involved both with some of the workings in the State of Texas
as well as the State of Connecticut recently, and there are a
relatively small number, 50 to 60 perhaps, set of procedures
when you are talking about pediatric dental care that cover the
vast gamut of common procedures that children need. If States
concentrate on making those rates attractive to dentists, they
can both be fiscally responsible and improve access to care.
Mr. Kucinich. I would really appreciate it if, for this
committee, if you would, as a followup, give us a letter that
would recommend, based on your experience, kind of a
prioritization.
Dr. Crall. I would be happy to do that, Mr. Chairman.
Mr. Kucinich. That would be helpful.
I would like to go to Dr. Casey.
How has adopting a preventive disease model both improved
the oral health of children and helped North Carolina reduce
Medicaid costs?
Dr. Casey. As of this time, Mr. Chairman, we have not been
able to demonstrate cost savings, but additional research is
ongoing. We are looking at pay claims over a long period of
time, up to 7 years of age. So you have to understand that it
is a complex research issue, and we hope in the future to
demonstrate cost savings to our program.
Mr. Kucinich. Did you have any plans to enhance that
program model?
Dr. Casey. I am sorry?
Mr. Kucinich. Do you have any plans to enhance the
preventive model?
Dr. Casey. Yes, we do. We are actually working on a pilot
model--and I address this a little bit in my written
testimony--a pilot model to facilitate referrals from
participating physicians to general dentists who have been
trained to see kids in this age group, zero to 3\1/2\ years of
age.
Mr. Kucinich. So if States were interested in creating a
prevention and disease control model, how would they go about
doing that? What would you recommend?
Dr. Casey. Well, I would recommend modeling their program
after something similar to ours. Other States have addressed
the issue, as well.
Mr. Kucinich. Now, did you get support from CMS when you
did that?
Dr. Casey. We did.
Mr. Kucinich. And so, from your experience, if the States
contact CMS at this point they would be ready to assist them,
based on your experience?
Dr. Casey. I think that CMS in disseminating information of
best practices, we plan to apply for a promising practices
designation for CMS to help them spread the word about our
program.
Mr. Kucinich. Thank you.
Mr. Finnerty, you mentioned that one of the reforms adopted
by Virginia was strengthening its relationship with the State's
dental community. Can you describe what that entailed and how
it worked to improve access and utilization of pediatric dental
care?
Mr. Finnerty. Mr. Chairman, I think that is probably the
most important thing that we did. Before we put into place any
of the reforms that we were able to achieve, the first thing
that I did as a Medicaid Director was to sit down with the
Executive Director of the Virginia Dental Association and say,
``what do we do to fix this program?''
We started a dialog actually 2 years before our reform
program actually went into effect, and the relationship that we
have developed not only helped to develop the program, but once
we had the program in place they were one of our biggest
advocates in trying to go out to their membership to say, Look,
the State has done what we have asked for. Now you all need to
step up and join this program and treat these kids.
It has been absolutely essential to it.
Mr. Kucinich. Why did you decide to increase reimbursement
rates? Did you think increasing reimbursement rates would have
been enough to improve access and utilization?
Mr. Finnerty. We increased the rates because they were
very, very low, particularly on some codes. They were less bad,
if that is the proper English, in some areas, but very, very
bad in others.
In terms of whether or not that would have been enough to
get increased participation, I think it would have helped, but
I really don't think that it was sufficient. I think that it
was a necessary part of the reforms, but without making the
administrative changes to the program I really don't think it
would have had the impact that the combined effect has had or
the combined effect of both administrative reforms and fee
increases.
Mr. Kucinich. So how did carving out dental out of the MCO
model impact access and utilization?
Mr. Finnerty. That, along with the fee increases, as I
mention in my testimony, has increased our utilization quite
significantly for children 3 to 20. We have seen a 55 percent
increase in utilizations from just prior to the start of our
new program, 2 years hence from that point in 2007. So it has
had a major effect. We would not have seen those increases
without the changes, I am very confident.
Mr. Kucinich. Now, in your testimony you mention that the
disruption of enrollment can disrupt care. Why is that the
case?
Mr. Finnerty. Well, when a child is receiving ongoing
dental care in Virginia, children can move between managed care
organizations. We have five of them that we contract with. If a
child is receiving ongoing care, if the child moved from one
plan to another and the dentist that was treating the child
initially is not a participating dentist in the other plan,
then that child is going to have to find another provider, and
so that is transitioning the care to another provider and that
type of thing.
Under our streamlined program, all of the dentists
participate and contract with one vendor, so, regardless of
what health plan they are in, they get their dental care
through one plan, and that has virtually been eliminated, the
problem of transitioning.
Mr. Kucinich. Thank you, Mr. Finnerty.
Ms. Lowe, according to your testimony, utilization of
dental care in Georgia did a turn-around between 2001 and 2007.
What do you think CMS could have done to stop this deleterious
trend?
Ms. Lowe. What could CMS have done, sir? I am sorry, I
didn't hear the last part.
Mr. Kucinich. What could CMS have done during that period?
Ms. Lowe. I think that the State was actually making
progress during that period because of the changes in the fees,
which went up, and also the changes in the administrative
approach to things, which greatly simplified how things were
going. That was over the period of 1999 to 2004.
Then, when the State eliminated those 11 dental codes from
payment, things crashed, and it crashed in the treatment area.
So possibly if CMS had said, sorry, you can't eliminate
payments or reduce payments for those codes, that would have
made a difference.
Mr. Kucinich. Well, did increasing reimbursement rates by
33 percent have any impact on access and utilization?
Ms. Lowe. Yes, it did. I think that was a major contributor
to the improvements that we saw over a period of years, but it
was pretty shocking how fast it could crash just because of the
budget cuts that subsequently took place.
Mr. Kucinich. So tell us what Georgia did to reform its
pediatric dental program under Medicaid, in a nutshell.
Ms. Lowe. In a nutshell, what they did over several years
was to raise the fees quite substantially until they were at
the 75th percentile. They also initially, when we were still
operating our payment system under the old EDS, which was
actually a DOS-based system and quite antique, at least
standardized the forms and used standard dental codes, which
had not been done before. Those two things together made a big
difference.
And then the State also changed to ACS from EDS and brought
the State into a Windows-based system for processing claims,
and that made a big difference eventually. It was a rocky
start, but eventually it made a big difference in the way
providers were able to file claims. They were able to check out
claims online. They were able to check eligibility online.
After that, after those improvements actually led to
increases in utilization and in the number of dentists
participating, the State did the budget cut, which eliminated
payment for some of the codes, and then decided that they would
require the children to enroll in capitated managed care. So we
have had those two disruptions.
Mr. Kucinich. Thank you very much.
I don't have any further questions of the panel. Does Mr.
Cummings have any questions?
Mr. Cummings. I just have a few questions, Mr. Chairman. I
apologize. It has been a very hectic day. I apologize to our
witnesses, but I am glad you are here.
Ms. Tucker, I have said many times that, in light of
Deamonte Driver's death, I was glad to see that Governor
O'Malley convened the Dental Action Committee to try to improve
children's access to dental care. Out of Deamonte's death--I am
sure it has been mentioned already--a lot of what we are doing
now came out of that. His death has had a profound impact.
I was further pleased to learn that the Dental Action
Committee adopted all of the recommendations that I provided to
the Governor, which is very unusual. I think the Governor took
this situation very seriously. And, of course, we will be
closely watching to see what goes on from here.
One of the changes that is currently in progress is the
move to a single vendor for providing Medicaid dental services
in the State of Maryland. Where are we in that process?
Ms. Tucker. We issued the RFPs in the early part of the
summer, and all of the proposals were due at the beginning of
September. We received five huge responses. Currently there is
a RFP Procurement Committee process going through to analyzes
all of the different vendors. It was a very, very complex RFP.
The requirements were quite extensive. So that committee is
going through and is in the process of picking the best of the
five people or groups that applied.
The goal will be to have that whole process done by the
beginning of December so it can go to our Board of Public Works
in January and be awarded so that we can begin the transition
to the new vendor starting March 1st.
Mr. Cummings. What kind of oversight do you anticipate
there being with regard to the vendor once they are chosen?
Ms. Tucker. The deliverables are quite extensive and
incredible, so there will be a lot, and there will be a lot of
oversight for this particular project. The Dental Action
Committee didn't go away after they put forth their proposals.
They are still an action committee. They are still going to be
involved. But the State, the Health Department will be
extremely involved in the day-to-day monitoring of that
contract.
Mr. Cummings. Now, Dr. Grover, again, I want to thank you
for your testimony also and thank you for all that you are
doing for children in Michigan, but I think your work is truly
an example of what dentistry has the power to achieve. I am
pleased also with many of the things that the American Dental
Association has done to improve children's access to dental
care across the country.
I am concerned, however, that some actions by the ADA may
have the opposite effect. You mention in your testimony the
ADA's recognition that a work force shortage exists in the
dental field and that alternate models need to be explored, and
I appreciate that recognition. But you also describe the ADA's
recognition for such a position as the community dental health
coordinator. I think this model is a solid concept and it ought
to be tested, but I do think other models ought to also be
tested.
Do you agree with this concept that other models of an
alternate dental provider should be tested?
Dr. Grover. I think that alternate models of providing
dental services, if they involve irreversible procedures, could
be potentially dangerous. In my experience as a dental
director, where I see the need to be the greatest is in helping
families work through the system and helping families keep
appointments, have transportation, and handle some of the
cultural and language barriers. Those models--and we have three
sites which are going to be piloted--will help the dental team
be more productive.
I think the challenge is in working with the families not
only to prevent disease but to navigate the system, which can
be quite burdensome for families to understand.
Mr. Cummings. Well, we saw that in the case of Deamonte
Driver. The mother of Deamonte, as you are, I am sure, well
aware, when trying to get services for his brother contacted
over 40 doctors who said that they would take patients on
Medicaid, and they weren't able to accomplish that. They even
went to a lawyer type person to try to help them, like a legal
type clinic, and still had problems. It is interesting. I
notice that what you just said, you brought up something that I
have heard dentists bring up over and over again, and I never
thought of it until we got involved in this issue, and that is
the issue of people keeping appointments. The dentists tell us
that one of the reasons why they are not that interested
sometimes in doing this kind of work is because the population
that they deal with, of course, don't show up for appointments.
Time is money, and they have but so many appointments they can
set in a day, and of course when people don't show up they
don't make money.
So the pilots that you are talking about, how do they
address that issue?
Dr. Grover. Well, the pilot program, for example, in
Jackson County, would help families that have appointments at
my dental clinic in my health center and would help us track
people who miss appointments. There is a variety of reasons why
people miss appointments. But confirming those appointments and
calling and, in fact, visiting the home of the family where
there is a missed appointment can help us track those children
more effectively and get them the care that they need. I think
that would complete the puzzle, because, quite honestly, I see
that as a huge barrier to folks. And it is not enough just for
my health center, which has a van, and my health center, which
confirms appointments, but to have somebody go to the home, to
have somebody work with the mom.
There are some community health workers in California that
do that, to help track these kids and make sure nobody falls in
between the cracks. There are too many that is happening to.
Mr. Cummings. Well, you know, it is interesting that when
you look at the way mothers take care of newborns, there are
certain things that seem to be clear that they must do, and
they do them. I think when you look at things like crib death,
things of that nature, the word has gotten out that you do
certain things to make sure that your babies survive. I am just
wondering, could we do a better job with regard to dental
education? I am sure you may all have gone over this. It seems
to me that a lot of people don't have a clue about how
significant the relationship is between the teeth and the rest
of the body. Not a clue.
So I would think that a mother and father, if they really
had a clear understanding of this relationship, that might be
helpful in, one, them staying on top of their dental
appointments and making sure that they made them, because I
don't think that when you get that well baby appointment--is
that what it is called?
Dr. Grover. Yes.
Mr. Cummings. I don't think a lot of people go about
missing those appointments. They know that they have to do
these things. But it seems to me that if people really know
that the health and perhaps the life of their child is
dependent upon them taking certain actions, it seems to me that
you might get some results there.
One of the things that we try to do in the SCHIP bill,
which the President vetoed twice, was a provision in it whereby
mothers would be exposed and fathers exposed to information
about dental care from the very beginning, from before the
child is born. They would be educated on that and provided
pamphlets, things of that nature.
I am just wondering what do you all do in that regard, and
what is ADA's position in that regard?
Dr. Grover. Well, the ADA position, you are absolutely
correct on many points. The ADA's position is to encourage a
dental home, and the first dental exam by 12 months of age.
What we are doing in Michigan, in particular, is we are
having a pediatric oral health summit where physicians and
dentists are coming together so that the physicians know what
they can talk and discuss with the mom. We at our health center
do have OB visits, particularly scheduled in special slots,
because we know that a significant factor in children receiving
oral health care is if the mom receives oral health care. That
is a big component.
I have also recently worked on a DVD for Delta Dental on
infant oral health care, and we would look forward to Delta
distributing that nationwide.
Education is key, as you have pointed out correctly.
Mr. Cummings. And what does the ADA want the Congress to
do? I am sure you have testified. What would you like to see us
do?
Dr. Grover. Well, we have an Essential Oral Health Care
Act, H.R. 2472, which we feel is key, but also to encourage CMS
to adopt some guidance for States that are making some headway,
that are making some successes, and encourage States to develop
similar models.
I think the rising tide lifts all the boats, and I think
what goes on in one State could go on in another.
I think we need to work at making oral health part of our
cultural conversation, and I don't know that is totally up to
Congress, but I am sure that would be a big help.
Mr. Cummings. All right. I don't have anything else.
Mr. Kucinich. I thank Mr. Cummings for the excellent work
that he has done on this matter from its inception, so thank
you very much for your presence here.
I want to thank the witnesses.
This has been a meeting of the Domestic Policy Subcommittee
of the Oversight and Government Reform Committee. The title of
today's hearing has been: Necessary Reforms to Pediatric Dental
Care under Medicaid. We have had two panels, and I want to
thank the members of the second panel for your contributions.
Each of you has helped to sharpen this committee's awareness of
where we have been, where we are headed, and what can be done
to improve pediatric dental care for the Nation's children.
Thank you for your own individual commitments in that regard
and the work that you have done in your respective capacities
on not only practice but in the States, as well.
I want to thank the Members and the staff who have
participated, and the staff, in particular, for the excellent
work they have done in researching this from the beginning.
Without any further comments, and finally with the
unanimous consent request to insert the testimony of Burton
Edelstein into the record, this committee stands adjourned.
[The prepared statement of Mr. Edelstein follows:]
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[Whereupon, at 1:25 p.m., the subcommittee was adjourned.]
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